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Accelerating the Rate of Progress in Reducing Mental Health Burdens:

Recommendations for Training the Next Generation of Clinical Psychologists
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Clinical Psychology: Science and Practice
© 2021 American Psychological Association 2021, Vol. 28, No. 2, 107–123
ISSN: 0969-5893 https://doi.org/10.1037/cps0000007
Accelerating the Rate of Progress in Reducing Mental Health Burdens:

Recommendations for Training the Next Generation of Clinical
Psychologists
Howard Berenbaum1, Jason J. Washburn2, David Sbarra3, Kathleen W. Reardon4, Tammy Schuler5,
Bethany A. Teachman6, Steven D. Hollon7, Marc S. Atkins8, Jessica L. Hamilton9, William P. Hetrick10,
Jennifer L. Tackett11, Meghan W. Cody12, Robert K. Klepac13, and Steve S. Lee14
1
Department of Psychology, University of Illinois at Urbana-Champaign
2
Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
3
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Department of Psychology, University of Arizona

4
Center for Applied Psychological and Family Studies, The Family Institute at Northwestern University
5
Fred Hutchinson Cancer Research Center, Seattle, Washington, United States
6
Department of Psychology, University of Virginia
7
Department of Psychology, Vanderbilt University
8
Institute for Juvenile Research, University of Illinois at Chicago
9
Department of Psychology, Rutgers University
10
Department of Psychological and Brain Sciences, Indiana University–Bloomington
11
Department of Psychology, Northwestern University
12
Mental Health and Behavioral Sciences, W. G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina, United States
13
Wilford Hall Ambulatory Surgical Center, Lackland Air Force Base, Texas, United States
14
Department of Psychology, University of California, Los Angeles
Despite criticisms dating back to the 1950s, and minimal progress reducing mental health burdens, the
dominant training model in clinical psychology has not changed. We argue that for clinical psycholo-
gists to reduce mental health burdens, they (collectively) need to devote a much larger proportion of
their professional efforts to a broader range of activities, particularly prevention. We propose a highly
flexible two-phase model for clinical psychology training. The initial Foundational Knowledge and
Competency Phase focuses on foundational concepts in the science of clinical psychology and direct cli-
ent care. During the Focused Competency Phase, students may continue training for traditional roles in
providing direct client care or, alternatively, develop other roles for using psychological science to
address mental health conditions.
Public Health Significance Statement

Clinical psychology has made little progress reducing mental health burdens. To address this shortcom-
ing, we recommend that clinical psychologists (collectively) devote a much larger proportion of their
professional efforts to a broader range of activities than they have in the past. A flexible two-phase
model for clinical psychology training is proposed to realize this goal.
Keywords: clinical psychology, mental health burdens, training
Howard Berenbaum https://orcid.org/0000-0003-4610-2195 notable contributions to this article and are listed second and third,
Jason J. Washburn https://orcid.org/0000-0003-0454-389X respectively. The order of the remaining authors was determined at
random.
Kathleen W. Reardon https://orcid.org/0000-0002-6372-9507
This work originated as a collaboration among colleagues affiliated with
Tammy Schuler https://orcid.org/0000-0003-3173-5918
the Coalition for the Advancement and Application of Psychological
Steven D. Hollon https://orcid.org/0000-0001-5005-3862 Science (CAAPS). This article is dedicated to the memory of the late Varda
William P. Hetrick https://orcid.org/0000-0003-3795-576X Shoham.
Meghan W. Cody https://orcid.org/0000-0001-9688-264X Correspondence concerning this article should be addressed to Howard
Robert K. Klepac https://orcid.org/0000-0003-3072-3077 Berenbaum, Department of Psychology, University of Illinois at Urbana-
Howard Berenbaum led the preparation of this article and is listed as Champaign, 603 East Daniel Street, Champaign, IL 61820, United States.
first author. Jason J. Washburn and David Sbarra made particularly Email: hberenba@illinois.edu
107
108 BERENBAUM ET AL.
Clinical psychology1 is both a discipline and a profession. As an particularly needed, not just by clinical psychologists but by the
academic discipline, it encompasses the scientific study of (a) psy- health care system more broadly, is a shift from a primarily dis-
chopathology and related problems in living and (b) the complemen- ease management approach to one of health promotion.
tary goals of promoting well-being and reducing, and ultimately What we mean by “traditional” research is the scientific work
eliminating, mental health burdens. As a profession, it is defined by typically conducted in Departments of Psychology and Psychiatry
the American Psychological Association (APA) as “the psychologi- aimed at generating generalizable knowledge. It is likely that clini-
cal specialty that provides continuing and comprehensive mental cal psychologists’ professional activities that go beyond traditional
and behavioral health care for individuals and families; consultation research and direct client care, such as public health policy analy-
to agencies and communities; training, education, and supervision; sis, administration, and prevention efforts, will include research,
and research-based practice” (APA, 2019). though often not exclusively for the purpose of generating general-
Even though most (89%) health service psychologists provide direct izable knowledge. For example, someone working in a public
client care, which along with administrative/management activities health department could conduct research to generate and refine an
account for a large majority (72%) of their time during a workweek algorithm for determining allocation of different levels of care;
(Hamp et al., 2016), clinical psychologists engage in a wide variety of someone in a leadership position in a healthcare system may col-
professional activities, such as directing clinics, programs, and agen-

lect and analyze data as part of a quality improvement project for a

cies; supervising (both other professionals and paraprofessionals); con- new system-wide initiative; someone working for a local school
sulting; developing and evaluating public policy; developing and district or municipal park system could conduct research to deter-
evaluating new programs; implementing and disseminating programs/ mine the level of interest in alternative prevention programs.
interventions; generating new knowledge by conducting research; and Currently, it is common for clinical training programs to be
disseminating knowledge to students/trainees, other professionals, and viewed through the lens of research versus practice. Consequently,
the general public. We argue that anyone who has obtained founda- we anticipate that many readers will be inclined to view our proposal
tional knowledge and competency (Rodolfa et al., 20052) in clinical through a similar lens. However, our proposal is not intended to priv-
psychology (which we describe below), along with advanced training ilege or to expand traditional research or practice. To the extent that
in the application of psychological principles, should be considered a our proposal is enacted and leads to greater flexibility and creativity,
clinical psychologist, assuming their professional activities focus on
we expect it to benefit training in research and practice, as well as
the application of that knowledge to promote well-being and reduce
areas beyond traditional research and practice. In other words, to
mental health burdens.3
effectively reduce the burden of mental health conditions, the field
The premise of our article can be summarized as follows. First, in
needs to move beyond the notion of graduate programs falling some-
the wake of World War II, clinical psychology in the United States
where on a research versus practice continuum. To accomplish this
experienced a rapid increase in size and shifted its focus from intellec-
goal, we propose that clinical psychologists expand the ways in
tual and personality assessment to the broader provision of direct client
which they can contribute to the reduction of mental health burdens.
care (i.e., implementing psychological assessments and interventions
We present a proposal intended to increase flexibility and crea-
with clients). Second, although it has helped numerous individuals, the
tivity in the training of the next generation of clinical psycholo-
burden of mental health conditions has not declined and, in fact, con-
gists4; the changes that follow from this proposal will enable
tinues to rise more or less unabated. In addition to the persistently high
prevalence rates of mental health disorders and the large gap in serv- clinical psychologists to more easily and successfully engage in a
ices received by those in need (see the section of the article titled “The wide range of professional activities. Our proposal is intended to
Burden of Mental Health Conditions”), Kazdin and Blase (2011) note be equally applicable to Ph.D. and Psy.D. training programs. The
the high cost in unmet need and lack of productivity with estimates of most important aspects of our proposal are that: (a) doctoral train-
$500 billion for the cost of services and almost $200 billion in producing be divided into two phases, each of which would take approxi-
tivity loss. In addition, suicide rates in the United States have increased mately 2-3 years to complete; (b) a Foundational Knowledge and
in the past decade for both adults (Woolf & Schoomaker, 2019) and Competency Phase would provide basic coverage of domains such
youth (Curtin & Heron, 2019), with recent rates for military veterans as psychopathology, assessment, intervention, and ethics (dis-
outpacing civilians for the first time on record (Smith et al., 2019). cussed below), and would provide all clinical psychology graduate
The National Institute of Mental Health (NIMH) estimates that students with competencies in the assessment and treatment of
nearly 50 million U.S. adults experience a mental health disor-
1
der. Clearly, mental health conditions are serious and highly Although this article focuses exclusively on clinical psychology, the
prevalent public health concerns, and these issues represent an issues raised and recommendations proposed may be applicable to
enormous unmet burden both in the United States and globally counseling and school psychology, with the three disciplines commonly
referred to as Health Service Psychology.
(https://www.nimh.nih.gov/health/statistics/mental-illness 2
We use the term “foundational competency” in a generic sense—we
.shtml.). Third, there is little reason to expect the status quo to are not referring to the six specific foundational competency domains
significantly reduce the burden of mental health conditions— described by Rodolfa et al. (2005).
rather, meaningful change is needed if clinical psychology is to 3
The activities aimed at promoting well-being and reducing mental
contribute to significantly reducing mental health burdens. health burdens may have an immediate impact (e.g., disseminating
Finally, the changes that are most likely to enable clinical psy- interventions, supervising paraprofessionals) or may be expected to have
an impact in the long run (e.g., conducting mental health policy analysis,
chology to make significant progress reducing mental health bur- carrying out research).
dens will require a marked increase in the proportion of clinical 4
We appreciate the thought-provoking and helpful comments provided
psychologists who engage in professional activities other than by numerous individuals, who shall remain anonymous, over the course of
direct client care and traditional research. What we believe is preparing this article.
TRAINING CLINICAL PSYCHOLOGISTS 109
most highly prevalent forms of psychopathology; (c) during the World War II, leading to a shift of clinical psychologists into the
Focused Competency Phase, students would obtain more specific realm of psychotherapy (Benjamin, 2005). In the 1940s and 1950s,
and individualized training consistent with the professional roles the roles of clinical psychologists outside of academia shifted
they wish to pursue as doctoral level clinical psychologists; (d) almost entirely to the direct provision of services for individual
students need not obtain any further training in direct client care clients or entities (i.e., dyads, families, groups). By the 1960s
during the Focused Competency Phase; (e) clinical psychology and 1970s, clinical psychologists had become well established in
training programs need not prepare all—or even any—students for private practices and had near parity with psychiatry—as
careers that predominantly focus on direct doctoral level client described by Benjamin (2005), “the golden age of clinical psy-
care; (f) all training not provided by doctoral programs can be chology had arrived” (p. 22). The golden age, however, quickly
postdoctoral (i.e., there will be no predoctoral internship5); (g) ended as managed care began to have an impact on clinical psy-
many students (necessarily including, but not necessarily limited chology in the 1980s (Benjamin, 2005), and competition from
to, those whose careers will focus on direct doctoral-level client master’s level clinicians, both within and outside of psychology,
care) will pursue full-time postdoctoral training experiences such has increased ever since (Cummings, 1995).
as those currently offered by members of the Association of Psy- The current template for the training of clinical psychologists
chology Postdoctoral and Internship Centers (APPIC), whereas emerged in the late 1940s and was shaped by the emerging empha-
others will pursue postdoctoral training experiences that focus on sis on the direct provision of services, especially psychotherapy.
different approaches for having a public health impact (e.g., influ- The federal government charged the Department of Veterans
encing policy); and (h) if enacted, our proposal will lead to few, if Affairs (VA) and the United States Public Health Service
any, changes in the training of clinical psychologists whose (USPHS) to work with the American Psychological Association to
careers will focus on direct client care, but large changes for develop and review doctoral training programs in clinical psychol-
those who want to apply their training beyond direct client care. ogy. In the summer of 1949, a conference at the University of Col-
Over time, we expect that more students will select career paths other orado, Boulder, convened experts to perform four key activities:
than direct client care and research if doctoral programs offer greater (a) outline a program for training in clinical psychology; (b) for-
flexibility in preparing them for those alternate career paths. We also mulate instructional standards in clinical psychology for both uni-
expect that new alternate career paths will be identified as doctoral versities and practicum sites; (c) evaluate and oversee training
programs become increasingly innovative and interdisciplinary. programs, including writing a report of each institution; and (d)
Although we focus our recommendations on changes to clinical psy- liaise with other organizations on mental health problems (Com-
chology doctoral programs, both to keep the scope manageable and mittee on Training in Clinical Psychology, 1947). Three key
because of our collective expertise in this field, we recognize that points in what evolved to become the “Boulder model” (Commit-
many of our recommendations may also apply to other allied fields tee on Training in Clinical Psychology, 1947) are particularly rele-
(e.g., industrial/organizational psychology, social work) given the vant to the future of training in clinical psychology: (a) an explicit
need to coordinate efforts to efficiently address the complexities of emphasis on providing trainees with foundational expertise that
reducing mental health burdens. could be leveraged into specialization later in their training; (b)
After presenting our proposal, we discuss the future of education cautioning against a one-size-fits-all training model and instead
and training in clinical psychology. Our goal for this article is to start affording training programs considerable flexibility in attending to
an open discussion about the future of clinical psychology, one that specific goals and needs; and (c) the importance of science inform-
will involve all relevant stakeholders and constituencies from the out- ing practice, and practice informing science. In recognition of this
set. Our hope is that these conversations can begin taking place on an interplay between science and practice, the Boulder model is com-
open discussion forum online and extend to other venues, including monly referred to as the scientist-practitioner model.
special issues of journals, dedicated conferences, and white papers Several alternative models intended to rethink training in clini-
outlining the procedural changes and a timetable for the reorganiza- cal psychology have been developed and implemented since the
tion of graduate programs, accreditation, and professional licensure. Boulder model, including the scholar–practitioner and clinical sci-
ence models (e.g., Baker et al., 2008; Levenson, 2017; Peterson
The Premise et al., 1997). However, all training models as currently imple-
mented have their roots in the Boulder model and share much of
Brief Historical Overview their training in common. For example, currently all doctoral and
Although contemporary clinical psychology is strongly associ- internship programs in clinical psychology in the United States are
ated with assessment and psychotherapy practice (Benjamin, 2005), designed to prepare students for entry level clinical practice. In
psychology, “clinical practice” has come to refer to the direct
this was hardly the sole thrust of clinical psychology at its origins.
delivery of services, most often in the form of psychotherapy and
For example, the founder of American clinical psychology, Light-
psychological evaluation. In fact, the “practice of clinical psychol-
ner Witmer, “conceived the role of clinical psychologists as extend-
ogy” has a specific legal meaning in many states. For example, in
ing well beyond the consulting room. In addition to intervening in
Illinois, the “practice of clinical psychology” is “subject to
schools, Witmer argued that clinical psychologists should engage in
preventive social action to change harmful social conditions”
5
(Humphreys, 1996, p. 190). Clinical psychologists continued to We are not the first to propose that the internship be postdoctoral. In
fact, slightly more than 20 years ago, the Council of University Directors of
play numerous roles across a wide range of settings through the Clinical Psychology (CUDCP) voted to make the internship postdoctoral,
1930s (Humphreys, 1996). However, the need for direct client care but the Association of Psychology Postdoctoral and Internship Centers
became increasingly salient during and immediately following (APPIC) voted to keep the internship predoctoral (Boggs & Douce, 2000).
regulations in the public interest to protect the public from persons Kazdin and colleagues (Kazdin, 2017, 2019; Kazdin & Blase,
who are unauthorized or unqualified to represent themselves as 2011; Kazdin & Rabbitt, 2013) describe a wide variety of alterna-
clinical psychologists or as being able to render clinical psycho- tives to the dominant model of psychosocial intervention delivery,
logical services as herein defined, and from unprofessional con- including changes to who delivers interventions, where interven-
duct by persons licensed to practice clinical psychology” (225 tions are delivered, and the nature of the interventions. Even if
ILCS 15/1). Thus, clinical practice, as it has come to be defined, there were no barriers to treatment, the discrepancy between need
represents only a subset of the range of applications of the aca- and availability would be immense. As noted by Albee (1990), the
demic discipline of clinical psychology. reason psychotherapy cannot solve mental health problems in the
United States is not that psychotherapy does not work but rather
The Burden of Mental Health Conditions because of the “unbridgeable gap between the enormous number
of people with serious emotional problems and the small number
As pointed out by others, including in a highly influential paper of therapists available” (p. 370). In the United States, approxi-
by Kazdin and Blase (2011), rates of mental disorders remain high mately 25% of the population (approximately 80 million people)
and largely stable, and the global burdens associated with mental experience a mental disorder in any 12-month period, whereas
health conditions appear virtually unaffected by empirical advan-

there are only slightly more than 100,000 licensed doctoral level
ces in prevention and treatment. Across the globe, nearly 20% of psychologists (Lin et al., 2016). The discrepancies in poorer coun-
people meet diagnostic criteria for a common mental disorder (typ- tries, including many of the most populous countries in the world
ically defined as a mood, anxiety, or substance use disorder) in (such as China, India, Indonesia, Pakistan, Nigeria, and Bangla-
any given year, and close to 30% of people have experienced a desh, which collectively account for approximately two-thirds of
common mental disorder in their lifetime (Steel et al., 2014). the world’s population), are orders of magnitude greater. This per-
Cross-national epidemiological data illustrate almost no change in son-power shortage has been known for at least 60 years (Albee,
the point prevalence of diagnosable anxiety disorders or major 1959), yet demand for psychologists, and mental health services
depressive disorder between 1980 and 2009 (Baxter et al., 2014), more broadly, will likely continue to exceed supply over the next
and after a period of decline, deaths from suicide have increased two decades (Bureau of Labor Statistics, U.S. Department of
30% from 2000 to 2016, especially among adolescent girls (Hede- Labor, 2018; U.S. Department of Health and Human Services,
gaard et al., 2018). Thus, the burden of mental health conditions is 2016). Behavioral health workforce shortages are expected to con-
enormous, and if anything, continues to increase, impacting tinue until at least 2025, at which point it is estimated that the
national economies, personal finances, lost work days, family dy- shortage of clinical, counseling, and school psychologists is
namics, prison systems, personal employability, and many other expected to reach almost 60,000 and the shortage of all behavioral
factors that affect quality of life and functioning across the United health professionals is expected to be approximately one quarter
States and worldwide6 (Trautmann et al., 2016; Vigo et al., 2016). of a million (National Academies of Sciences, Engineering, and
Two factors, also noted by others, contribute in significant ways to Medicine, 2017). The impact of COVID-19 on mental health prob-
the failure to reduce the burden of mental health conditions: (a) the lems has exacerbated the mental health treatment gap and has fur-
mental health treatment gap and (b) insufficient attention to preven- ther revealed the need for clinical psychologists to be capable of
tion (e.g., Albee, 1990; Atkins & Frazier, 2011; Kazdin & Blase, responding in novel, creative ways (Gruber et al., 2020).
2011). The mental health treatment gap is the discrepancy between There can be little doubt that the most efficient means of reduc-
those who have mental health conditions and those who receive treating the burden of mental health conditions would be to reduce
ment for mental health conditions. For example, in the United States, their incidence. According to the National Prevention Council
only between 15% and 30% of people in need of mental health serv- (2011), “preventing disease and injuries is key to improving
ices actually receive any (Kessler et al., 2005), with racial and ethnic America’s health” (p. 6), and according to the American Psycho-
minorities especially unlikely to receive services (e.g., Satcher, logical Association’s Guidelines for Prevention in Psychology
2001). Notably, the treatment gap is substantially higher in poorer (American Psychological Association, 2014), “the effectiveness of
countries. For example, in China only approximately 3% of people in prevention to enhance human functioning and reduce psychologi-
need of mental health services actually receive any, and in Nigeria cal distress has been demonstrated” (p. 285). Psychology and other
less than 1% receive services (World Health Organization [WHO] mental health professions have taken two approaches to preven-
World Mental Health Survey Consortium, 2004). tion: public health (population-level interventions) and develop-
The mental health treatment gap is largely the result of substan- mental (modifying risk and resilience across individuals’ growth
tial barriers to treatment and shortages of mental health professio- trajectories; Beck & Cody, 2016). Both approaches use a three-
nals. There are numerous barriers to treatment, including financial stage prevention research cycle, consisting of: (a) etiological stud-
(e.g., Kessler et al., 2001), geographic (e.g., Andrilla et al., 2018; ies of risk and resilience factors; (b) clinical trials of preventive
Cummings et al., 2017), and cultural (e.g., Leong & Kalibatseva, interventions; and (c) implementation and dissemination of pre-
2011). Perhaps the most important barrier was noted by Kazdin ventive interventions into the community. To date, the vast
(2019), who wrote,
6
Even if one conceptualizes mental health from a dimensional
a key barrier is the dominant model of delivering psychosocial interven-
perspective and assumes that there will always be a continuum of mental
tions. That model includes one-to-one, in-person treatment, with a trained health with some individuals falling at both ends of the continuum, we
mental health professional, provided in [a] clinical setting (e.g., clinic, believe it should be the mission of clinical psychology to reduce absolute
private practice office, health-care facility). That model greatly limits the levels of distress and disability, including objective outcomes such as
scale and reach of psychosocial interventions. (p. 455) suicide rates (which, as already noted, are increasing).
majority of work on the prevention of mental disorders falls within educate and train clinical psychologists, providing direct client
the first two stages of the cycle, with the dissemination of newly care by clinical psychologists will be hopelessly inadequate for
developed effective interventions identified as a priority for psy- addressing the burden of mental health conditions in under-
chologists over the next decade (Muñoz et al., 2012). resourced countries (that include the large majority of the world’s
Recommendations for accelerating progress in prevention sci- population) where the current per capita number of mental health
ence emphasize new activities and roles for psychologists, includ- professionals is a tiny fraction of that in wealthy countries.
ing development and implementation of interventions led by Another option is for the field to move in ambitiously innova-
paraprofessionals, integrating mental health promotion and univer- tive directions that have the potential to significantly reduce men-
sal prevention into primary health care settings, and expanding the tal health burdens worldwide. Clinical psychology is well
focus of prevention programs from individual-level targets to positioned to do so—clinical psychologists have a long history of
larger social/environmental systems (Beck & Cody, 2016). Even playing a wide variety of roles other than direct client care, such
though prevention efforts will be critical to reducing the burden of as engaging in prevention efforts, training multiple professions
mental health conditions, since the Boulder Conference, the educa- and non-professionals to deliver evidence-based interventions, and
tion, training, and practice of clinical psychologists have empha- engaging in mental health policy analysis. The goal of our pro-
sized direct client care for people who have already developed posal is to facilitate these different ways of making an impact, as
mental health conditions. well as to encourage the development of new and innovative ways
The evidence appears clear: To significantly reduce the burden to reduce the burden of mental health conditions. Furthermore,
of mental health conditions, it will be necessary to both move clinical psychology has long focused on understanding the multi-
beyond the current dominant model of delivering psychosocial ple contributions to mental health outcomes, from the molecular
interventions one-to-one in traditional clinical settings and to level to the environment and social context (e.g., Baer et al., 1968;
increase attention to prevention. Indeed, Atkins and Frazier Gottesman & Shields, 1972). There is growing evidence that life
(2011) argued that it is critical for clinical psychology to develop experience and the environment influence gene expression (i.e.,
a “comprehensive and integrated public health model.” As an epigenetics; e.g., Lau & Eley, 2010; Morrison et al., 2019) and
illustration with children’s mental health services, these authors brain development and functioning (e.g., Koss & Gunnar, 2018;
proposed that resources be distributed equitably across the con- Strüber et al., 2014). By building more flexibility into doctoral
tinuum from prevention to intervention, including mental health training so that new areas of inquiry can more readily be exam-
promotion at the universal level, prevention focused on natural ined, clinical psychology can play a critical role in conducting and
settings (e.g., school districts and parks), targeted interventions then harnessing the scientific study of these large forces (e.g., the
that prioritize care for high-risk groups, and evidence-based intersection of neuroscience and genetics with environmental and
treatments that can be delivered with high fidelity in community social factors) to promote a new understanding of prevention and
settings. If such an approach were to be employed more broadly, treatment possibilities (e.g., Fisher et al., 2016).
clinical psychologists could contribute to reducing mental health Clinical psychology is also at a crossroads in terms of the utili-
burdens in a wide variety of ways, including: (a) continuing to zation of digital and mobile technology for assessment, preven-
directly deliver evidence-based treatments to people who have tion, and treatment of mental health conditions (Fairburn & Patel,
already developed mental health conditions; (b) leading and 2017; Marzano et al., 2015; Mohr et al., 2017), just as are other
training others to deliver evidence-based prevention programs areas of health. As the World Health Organization (2011) noted,
and treatments; (c) developing, implementing, and disseminating “The use of mobile and wireless technologies to support the
more effective and efficient evidence-based interventions; (d) achievement of health objectives (mHealth) has the potential to
conducting research intended to lead to the development of transform the face of health service delivery across the globe” (p.
improved interventions, especially those that extend beyond one- 1). Importantly, novel digital mobile health and web-based
to-one, in-person interventions in traditional settings, such as approaches, ranging from real-time autonomous interventions
direct-to-user digital interventions; (e) developing and imple- using wearable sensors or self-tracking technologies to clinician-
menting improved means of identifying those at highest risk for supported digital interventions, have the potential to radically
mental health conditions; (f) working to develop and implement change what intervention looks like and address the severe limita-
prevention efforts in non-clinical/medical settings, ranging from tions of the one-on-one, in-person assessment and intervention
barber shops and hair salons (see Victor et al., 2018) to social model that currently dominates clinical psychology (Kazdin &
media platforms and embedded sensors in personal computing Blase, 2011). The WHO (2011) estimates that there are over 5 bil-
devices; and (g) using clinical psychological science to inform lion wireless subscribers globally, with 70% of them residing in
public policy (see Novak & Brownell, 2011, for an example). low- and middle-income countries, and commercial wireless sig-
nals cover more than 85% of the world’s population. Accordingly,
Clinical Psychology Is at a Crossroads clinical psychology is faced with an opportunity to greatly expand
its impact by incorporating research and practical training that will
As we see it, clinical psychology is faced with a choice. One enable its graduates to alleviate the burden of mental health condi-
option is to continue with the status quo. Clinical psychology tions through innovations in digital and mobile health.
would continue to be a noble profession, with clinical psycholo- Mobile health and other alternative delivery models will only be
gists providing relief to a subset of people who have already devel- one part of the solution. Innovation, with or without technology, is
oped mental health conditions. But the status quo has not—and desperately needed to address the burden of mental health condi-
cannot—be expected to significantly reduce mental health bur- tions. A critical argument for innovation, and perhaps even a road-
dens. Moreover, given the substantial resources necessary to map, is inspired by the early history of clinical psychology. As
noted earlier, one of the founders of American clinical psychology, in each domain)—competencies in these areas can be achieved in
Lightner Witmer, envisioned clinical psychologists working in a a variety of ways, and it is up to doctoral programs to ensure stu-
variety of settings, and not only treating individuals, but also tar- dents’ competencies and to achieve these competency endpoints as
geting environmental factors that contribute to psychological prob- they see fit; (b) programs be permitted, if not encouraged, to cus-
lems. Sarason (2003), writing as one of the last surviving tomize training in each domain to the career goals of the individual
participants in the Boulder Conference, lamented the disregard for student, particularly for those students not pursuing a career
the promotion of wellness and the prevention of problems. He involving direct client care; and (c) training programs not be
noted the need for clinical psychology to return to its roots and to required to provide training beyond these domains.
encourage engagement in a broader range of activities. However,
for clinical psychologists to take this leap, significant changes will A New Multiphase Training Model for Clinical
need to be made to training programs in clinical psychology. Psychologists
The Proposal We propose that doctoral training in clinical psychology be

divided into two phases, each of which would take approxi-
In keeping with the views of the framers of the Boulder model mately 2-3 years to complete.7 The first phase, which we refer
that a one-size-fits-all approach be avoided, we recommend that to as the Foundational Knowledge and Competency Phase,
the training of the next generation of clinical psychologists be as would cover the essentials of the 10 domains described in Ap-
flexible as possible. Also consistent with the framers of the Boul- pendix A. This first phase would also provide all clinical psy-
der model, we propose that all trainees be provided with founda- chology graduate students with a foundational level of
tional knowledge and competencies, followed by focused training competency in delivering science-based methods for diagnos-
and specialization guided by students’ interests and career goals as ing mental disorders, identifying transdiagnostic markers of
well as emerging public health needs. The foundational competen- vulnerability and dysfunction, case conceptualization, treat-
cies should provide skills that can be applied broadly and flexibly ment planning, transdiagnostic prevention and intervention
throughout their career, including in ways we currently may not be strategies, and outcome monitoring for highly prevalent prob-
able to imagine. Our proposal is also consistent with one of the lem areas. Thus, this first phase will enable programs to con-
hallmarks of the Boulder model, that science and the application tinue providing an integrated training period during which
of psychological science inform one another. the curriculum covers both the foundational competency/
Most notably, we argue that not every clinical psychology train- knowledge components and hands-on training in direct service
ing program needs to prepare all—or even any—students for delivery.
careers that predominantly focus on direct client care. Instead, we Developing these direct service delivery competencies dur-
propose that the field embrace a plurality of training models, ing the foundational phase is feasible, as there is mounting evi-
including new and innovative models. To accomplish this, pro- dence that competence in delivering common elements of
grams will need the latitude to prepare students for myriad careers therapeutic change can be achieved in substantially less time
and to engage in a wide range of activities. Some clinical psychol- than is typical in a doctoral program in clinical psychology. For
ogy training programs will continue to expect most or all of their example, a recent systematic review found a pooled effect size
graduates to pursue traditional careers devoted primarily to direct of 0.49 (95% CI [0.36, 0.62]) for psychological treatments of
client care. Alternatively, other programs may choose to focus common mental disorders that were delivered by health work-
their education and training on activities that do not involve direct ers without specialized mental health training (Singla et al.,
client care, such as the development and utilization of large-scale 2017). These nonspecialist providers achieved medium to large
digital and mobile health services, primary prevention, public pol- effects after receiving about 80 hours of training in delivering
icy, or implementation/dissemination. Although we propose that established elements of therapeutic change. Thus, it seems very
all students obtain foundational knowledge and competencies in realistic that within the 2–3 years of the Foundational Knowl-
the delivery of behavioral health services, doctoral programs edge and Competency Phase, students could develop founda-
should not be required to prepare students for careers that empha- tional competencies in the assessment and treatment of most
size direct client care. highly prevalent forms of psychopathology (e.g., mood, anxi-
We propose that the ten domains described in Appendix A con- ety, and substance use disorders). Assuming such competencies
stitute core foundational learning domains across doctoral pro- are sufficient to obtain Master’s level licensure to deliver serv-
grams in clinical psychology. Not surprisingly, the ten domains ices, we expect that completion of the Foundational Knowledge
described in Appendix A overlap considerably with what is cur- and Competency Phase would provide all students with the
rently covered in virtually all clinical psychology doctoral pro- option of obtaining such licensure, even prior to completion of
grams. In Appendix A, we provide the rationale for covering these their doctoral studies.
domains, ways in which coverage of these domains has evolved The essential knowledge and training in clinical psychology
and is likely to evolve in the future, and ways in which programs provided during this foundational phase would provide the base
may currently cover these domains differently. upon which a student would then engage in focused training in an
What we think is most important is not the list of domains, but area of specialization during their second phase of graduate
rather our call for greater flexibility in how these domains are cov-
ered. To maximize flexibility, we recommend that: (a) training 7
Ultimately, the length of time required for each phase of graduate
programs be given latitude in how they go about providing train- training should be determined on the basis of the length of time needed to
ing in these domains (including the quantity and format of training obtain competence.
training, as well as for further specialization8 and shifts in interests time aide to a state legislator). As this example demonstrates,
over the course of a career.9 We refer to the second phase of edu- although all students will take some form of practica during the
cation and training in clinical psychology as the Focused Compe- Focused Competency Phase, the focus of the practica during this
tency Phase, during which students obtain more specific and phase need not be in the provision of direct client care.
individualized training consistent with the professional roles they
wish to pursue as doctoral level clinical psychologists. During this Implications for Postdoctoral Training, Internship, and
second phase, students will continue to receive training in at least Beyond
some of the 10 domains described above. However, during this
phase, the domains that are covered will vary from student to stu- It will be incumbent on doctoral training programs in clinical psy-
dent, and such training is expected to be more advanced and cus- chology to ensure that their graduates are well prepared for and can
tomized to students’ specific career interests. succeed in existing and, in many cases, yet-to-be-discovered, career
For some students, the focused training during this second phase paths that promote science to understand, reduce, and prevent mental
will be in some area(s) of direct client care (akin to the current norms), health burdens, and to foster adaptive development and well-being.
whereas for other students this focused training need not include any Those students who wish to pursue careers providing direct client
direct client care. This approach will allow programs to develop, in a care will be expected to complete a relevant full-time training experi-
nimble and unconstrained manner, innovative training programs in ence such as those currently offered by members of the Association
response to the latest research, technology, policy, and healthcare of Psychology Postdoctoral and Internship Centers (APPIC). To max-
trends. Moreover, this approach will allow for a depth of study that we imize flexibility and promote innovation in doctoral training pro-
believe is essential to prepare clinical psychologists to have a meaning- grams, we propose that predoctoral internships, which currently focus
ful impact on mental health burdens. Our argument is that many more on training students to provide direct client care, become postdoctoral
opportunities will exist if the graduate training structure in the field is (consistent with most other health professions), rather than remain
more flexible and less time is spent preparing all students for internship integrated into the doctorate. Students with goals and career paths that
as a predoctoral requirement. We anticipate that this model will result include direct client care would complete a postdoctoral fellowship
in a greater variety of programs available to clinical psychology stu- that would be functionally equivalent to current internships, allowing
dents, as well as the types of careers that students could pursue. For those students to pursue licensure at the doctoral level, and ultimately
example, programs may prepare students for careers in the following: board certification in their area of specialty. By moving to a postdoc-
mental health economics and policy; dissemination of best psychologi- toral model, with foundational competencies in direct client care hav-
cal knowledge and practices; developing, implementing, and evaluating already been established during the Foundational Knowledge and
ing mobile and digital mental health interventions; and leadership roles Competency Phase, these direct client service training experiences
in community mental health. This model provides the time and flexi- during the postdoctoral fellowship could provide more focused train-
bility for programs to prepare students for a wider variety of careers ing in specialties and subspecialties in clinical psychology.
than is currently possible, allowing clinical psychology to be more re- Students who do not plan to pursue careers in direct client care
sponsive to developments in the health needs of the population, as could pursue a variety of postdoctoral training experiences, the
well as advances in our knowledge. precise nature of which would depend on their goals and career
In comparison with the current model of training, our proposal paths. For example, someone whose career goal is to work with
will likely result in greater variation in what knowledge is taught Non-Governmental Organizations (NGOs) in low- and middle-
and what skills are trained across both programs and students, par- income nations would benefit more from full-time training in the
ticularly during the Focused Competency Phase. Programs and field with NGOs (e.g., internship at the WHO) than by pursuing a
students will continue to share a strong focus on the application of traditional internship. Likewise, someone whose career goal is to
scientific knowledge and psychological principles to whatever develop and evaluate mental health policies would benefit more
work they do (e.g., direct client care, mental health policy analysis, from a full-time field experience in a setting that develops or
implementation, and dissemination). Similarly, all students would implements mental health policies than from an internship focused
continue to participate in practica during the Focused Competency on direct service delivery—an example of such an existing post-
Phase, although the nature of the practica will vary. Some stu- doctoral fellowship is the SRCD U.S. Policy Fellowship Programs
dents, particularly those intending to pursue careers as providers (https://www.srcd.org/professional-advancement/srcd-us-policy-
of direct client care, will complete practica involving direct provi- fellowship-programs). Making internships and other full-time,
sion of psychological assessment and intervention. As is the case year-long training experiences postdoctoral would provide stu-
now, students planning careers as providers of direct client care dents the maximum flexibility in curating a training program that
would take practica focusing on direct client care throughout most is aligned with their goals and interests. Providing doctoral pro-
of graduate school. In contrast, for those students pursuing career grams with complete control over the training of their students
paths other than direct client care as a doctoral-level clinical psy- prior to graduation would facilitate innovations in graduate train-
chologist, extensive training in direct client care beyond that pro- ing, ultimately making it more likely that clinical psychology
vided during the Foundational Knowledge and Competency Phase could contribute to substantial reductions in the burden of mental
likely makes little sense. For example, a student whose career goal
is to work in government or as part of a policy think-tank to de- 8
Some graduates of clinical psychology doctoral programs may choose
velop and evaluate health policies aimed at reducing the burden of to return to school to respecialize at a later point in their career, and some
mental health conditions would be better served by taking courses training programs may develop specialized programs for this purpose.
in social and political psychology, epidemiology, and health pol- 9
A comparison with training models in Europe is presented in
icy, and by taking practica in government settings (e.g., as a part- Appendix B.
health conditions. If the current predoctoral internship (most of some might assume that since we list 10 core foundational learning
which focus primarily, if not exclusively, on direct service deliv- domains that we are prescribing 10 required courses (one per do-
ery) were to be retained, doctoral programs and their students main). However, there is no reason why training in all, or even any,
would need to focus on direct service delivery so that students of the 10 domains need to be provided in the form of traditional
would be adequately prepared for such internships (and capable of classes. In fact, the most compelling evidence suggests that students
competing for the limited number of slots), and programs and stu- learn by doing (Davidson, 2017), and this learning can take place in
dents would be unable to devote the necessary time and attention a context that is both problem-oriented and student-centered. Thus,
to career paths other than direct service delivery. Put simply, we anticipate less and less training to occur via traditional classroom
requiring that all students prepare for and then complete a predoc- instruction.
toral internship that focuses primarily, if not exclusively, on direct It is likely that many in the field, including the authors, have
service delivery is inconsistent with the goals of our proposal. assumptions about training that extend well beyond the issue of tradi-
It is important to note that the proposed changes to the current tional classroom instruction. For example, some may assume that it
structure of the predoctoral internship will lead to few, if any, must be the responsibility of all doctoral-level clinical psychology
training programs to ensure that its graduates are license-eligible. We
changes in the training of clinical psychologists who wish to focus

are optimistic that should the flexibility and creativity of training in
on direct client care in their careers. Even those who do not plan
to include direct client care in their careers may choose to pursue clinical psychology be encouraged, innovation will follow. For exam-
postdoctoral training that includes direct client care to further ple, we would expect that with time, training programs would add
their career goals (e.g., clinical leadership, treatment develop- new minors and specialization opportunities that focus on ways to
ment, dissemination/implementation). However, the proposed apply our skills beyond traditional research and direct client care. We
changes will make it more feasible for programs and students to anticipate the emergence of innovative interdisciplinary hybrid pro-
train for a wider array of career paths beyond direct client care, grams (e.g., clinical psychology/public policy), jointly housed or
should they wish to. In Table 1, we illustrate the required training sponsored by multiple academic units, that both in principle and in
and credentials, based on our recommendations, for several sam- practice are far more than the sum of two separate programs/degrees
ple careers/positions. that already exist. Just as there is potential for synergy when clinical
psychology programs combine with other academic units and pro-
Identifying and Questioning Assumptions grams within their home universities, there is enormous potential for
cross-institution collaborations. As distance learning and collabora-
Our proposal is intended to encourage flexibility for both training tion increases, and if exchange of faculty and students across institu-
programs and students. This will require questioning our assumptions tions becomes more common, we can envision “doctorates without
about training, some of which we may not even recognize. For exam- borders,” with multiple institutions working collaboratively to train
ple, based on how most training programs have operated for decades, the next generation of clinical psychological leaders and innovators.
Table 1
Sample Careers/Positions and Their Required Training and Credentials
Community Mental Public Executive Director of
Medical Center VA Research Health Center University Professor Policy a Large Behavioral
Professional title Psychologist Psychologist Program Manager of Psychology Analyst Health Agency
Weekly activities Works primarily as a Engages in an 80/20 Coordinates wellness Involved in research, Works on Works exclusively as
neuropsychologist, (research/direct programs and con- teaching, and clini- mental an administrator,
providing clinical client care) split ducts occasional cal supervision of health overseeing all
services, teaching intake interviews common mental policy aspects of the
and supervision disorders within agency
the training clinic
Foundational direct
client care
competency
required? Yes Yes Yes Yes Yes Yes
Master’s Level
Direct Client Care
Licensure
Required? Optional Optional Yes Yes No No
Postdoctoral direct
client care intern-
ship required? Yes Yes No No No No
Postdoctoral direct
client care licen-
sure required? Yes Yes No No No No
Board certification
for a psychological
intervention and
assessment spe-
cialty required? Yes No No No No No
The Future than being chefs in restaurants (while retaining foundational train-
ing for all of their students in nutrition science and basic food
We believe that clinical psychology is at a crossroads. The field preparation). These educators recognized that if it were desirable
can choose to stick to the status quo, focusing primarily on direct to have far more of their graduates engage in professional activ-
one-to-one client care and traditional research. Although this ities other than being chefs in restaurants, and if they wished to
option would enable clinical psychologists to continue helping the optimally prepare their students for such careers, their programs
few, it would likely preclude clinical psychology from playing an should devote significant effort toward preparing students for such
important role in significantly reducing the burden of mental careers, rather than relying on their graduates to retool following
health conditions. Instead, we hope the field chooses to be for- graduation. Individual training programs were unwilling to imple-
ward-looking and to make changes that will contribute to signifi- ment the proposal because it would mean losing their accredita-
cant reductions in mental health burdens. By expanding the tion. Many were reluctant for the field to adopt the proposal for a
breadth of roles to be played by clinical psychologists, and variety of reasons: (a) because it would require substantial reor-
increasing the flexibility of training, our proposal also has the ganization of the field—from funding models to accreditation to
potential to attract a more diverse pool of individuals to the field. licensure; (b) because of fears that there would be fewer well-
We recognize that the current training model does allow stu- trained chefs in restaurants; and (c) because it had yet to be tried
dents to obtain some training beyond direct client care and tradi- anywhere, and there was no guarantee that implementing the pro-
tional research. However, we believe that the proportion of posal would reduce nutritional problems any more than the old
training time dedicated to specific professional roles needs to shift system. But all of the available evidence clearly indicated that the
dramatically to allow for greater opportunities beyond direct pro- old system was not making a substantial dent in the country’s
vision of client care and traditional research. Moreover, this flexi- nutritional problems, whereas the proposed new system had the
bility is needed at multiple stages of training—we propose that potential to do so.
programs can elect to use the Focused Competency Phase to target Making changes will be challenging not just because of inertia
impact areas (e.g., policy, dissemination) that do not involve but also because of fears about modifying a field that has many
ongoing training in direct provision of client care or traditional reasons to be proud. Although we cannot prove, in advance, that
research, and we propose to change the internship model so that it eliminating the requirement that all students pursue training for
occurs at the post-doctoral level and the focus can be on whatever doctoral level direct client care will ultimately lead a greater num-
impact area that graduate wants to specialize in (e.g., it could be ber of clinical psychologists to engage in professional activities
direct provision of client care but could just as easily be some other than direct client care, it seems like a very likely outcome.
other area, such as community prevention work or the develop- Some may worry that, if enacted, our proposal will lead to fewer
ment and evaluation of mobile technologies for improving mental clinical psychologists being providers of direct client care, which
health). If the goal is to increase the number of clinical psycholo- will in turn expand rather than reduce the mental health treatment
gists who engage in professional activities other than direct client gap. However, estimates of future mental health treatment gaps
care and traditional research, and improve how they are trained to are based on assumptions regarding incidence rates and means of
do so, we need greater flexibility and innovation, and programs delivering mental health care. We predict that the loss of clinical
intentionally designed to achieve this goal. psychologists engaged in direct client care will be more than com-
We present the following (admittedly simplistic) analogy to pensated for by the reduction in need that would result from
illustrate why proposals like ours are worth trying to implement increasing the number of clinical psychologists who engage in pre-
but have yet to be attempted. Imagine a country in which there vention and the development of novel means of delivering mental
existed hundreds of “food and nutrition” training programs which, health care. Ultimately, our proposal is based on a public health
for odd historical reasons, had as their goal producing graduates perspective, shared by others such as the WHO (2011) and the
who became chefs in restaurants. To obtain their degrees, students National Prevention Council (2011), positing that alternatives to
had to complete a full-time, year-long internship working in a res- direct client care as currently delivered, such as a shift to preven-
taurant as a chef-in-training. Further, it was not possible for a tion and the use of mobile and other emerging technologies, stand
training program to be accredited if all of its students did not com- the best chance of improving health outcomes at a population
plete such internships and were not prepared to be chefs in restau- level.
rants upon graduation. Not surprisingly, most graduates ended up We are not, of course, expecting clinical psychology to single-
working as chefs in restaurants, though occasionally a graduate handedly reduce mental health burdens. In fact, one of the most
would pursue additional training following graduation so that they important ways clinical psychology can contribute is by collabo-
could pursue alternative career paths, such as being in charge of rating with professionals in other fields that are relevant to mental
food preparation/delivery in institutional settings (e.g., schools) or health and well-being. To the degree that clinical psychologists
developing nutrition enhancement programs for community organ- have expertise beyond direct client care (e.g., in terms of preven-
izations. When, after such programs had existed for more than half tion, public health, and the development and delivery of interven-
a century, it was recognized that the prevalence and impact of tions via mobile technology), we expect them to be more inclined
nutritional problems had not declined, a number of educators pro- and better able to engage in interdisciplinary work with professio-
posed that their programs not be required to train all of their stu- nals in other fields to influence mental health care practice and pol-
dents to work as chefs in restaurants, that not all of their students icy. Although we do not think clinical psychologists are unique in
be required to complete internships in restaurants, and that pro- their ability to engage in interdisciplinary work and to contribute
grams be given the latitude to intentionally train some or all of in novel ways to reduce mental health burdens, we do believe they
their students to address nutritional problems through means other are particularly well positioned to do so given psychology’s
breadth (from molecules to communities) and its historical atten- doctoral level direct service delivery in our proposed system
tion to prevention. would be almost identical to that obtained in the current system,
Although we hope the field can move in new directions, and we the changes that would need to be made to the licensure system to
believe there is merit to our proposal, we are not so presumptuous accommodate the proposed changes would be negligible. The pro-
as to believe that our proposal is perfect. We are open to the possi- posed model would continue to support the goal of state licensing
bility that alternative training models may have an equal or greater bodies to protect the public regarding the direct provision of clini-
likelihood of enabling clinical psychology to contribute to reduc- cal services (i.e., assessment and therapy). Under the proposed
ing mental health burdens. We view this article as the beginning of model, eligibility for licensure at the doctoral level will require
a discussion and process of change, not as an end point. We are that students not only graduate with their doctoral degree, but also
hoping this article will begin a conversation, to be continued via complete postdoctoral training in direct service delivery that satis-
an open online discussion, about the future of clinical psychology. fies a state’s requirements for training beyond practica. We recom-
We recognize that implementing changes will be quite challeng- mend that the year-long, full-time direct service delivery
ing, and the practical demands of restructuring the field will be postdoctoral internship (that would replace the current predoctoral
daunting. By far the biggest changes would need to be made by internship) fulfill such requirements. Essentially, whatever laws or
doctoral training programs. For example, how, if at all, would rules guide licensure in any given state would need to be amended
individual programs choose to structure their curricula? For pro- to state that a postdoctoral internship was necessary (as opposed to
grams that wish to continue preparing all or the vast majority of a predoctoral internship being necessary). But it would ultimately
their students for careers in direct service delivery, the changes be up to the state licensing boards to decide if they were willing to
would likely be rather minor, with the biggest challenge being do so. That said, if the relevant accrediting agencies (specifically,
how to demarcate the two phases of training (i.e., the Foundational the APA Commission on Accreditation [APA-CoA] and the Psy-
Knowledge and Competency Phase and the Focused Competency chological Clinical Science Accreditation System [PCSAS]), the
Phase). Fortunately, attempts to address this challenge can build Association of Psychology Postdoctoral and Internship Centers
on work already devoted to the subject of how to structure training (APPIC), the American Board of Professional Psychology
for clinical psychologists (e.g., Hannay et al., 1998; Klepac et al., (ABPP), and the Association of State and Provincial Psychology
2012). Likewise, it is expected that whatever changes are consid- Boards (ASPPB) were to agree on changes and recommend model
ered in doctoral programs and beyond will build on the competen- legislation/rules, licensing laws/rules across the country could be
cies movement and literature (e.g., Kaslow et al., 2007; Rodolfa & changed.
Schaffer, 2019). To the degree that doctoral programs wish to pre- If our proposal were to be adopted, it may well have an impact
pare students for career paths other than direct service delivery, on reimbursement for direct services delivered by (a) graduate stu-
the changes would be more extensive and challenging. dents after they obtain Master’s level licensure and (b) interns,
In theory, doctoral training programs can make whatever because they will have their doctoral degree when they begin their
changes they wish. However, in practice, there are several poten- internship. Changes in reimbursement have the potential to be ben-
tially significant obstacles to change. First, we can envision eficial or harmful depending on one’s perspective. For example,
remarkably few, if any, doctoral programs being willing to give up sites at which advanced graduate students provide direct service
their accreditation, which would likely be the outcome of enacting delivery may be able to obtain higher levels of reimbursement
the sorts of changes we are proposing (e.g., despite providing all when those graduate students have Masters level licensure. Like-
students with foundational direct service competencies, not prepar- wise, internships may be able to obtain higher levels of reimburse-
ing all of them for doctoral level practice; granting the doctoral ment when their interns already have doctoral degrees. Interns
degree prior to completion of the internship). Therefore, for our may be in a position to expect higher salaries when they already
proposal to be implemented, changes to accreditation criteria possess a doctoral degree than when they do not. On the other
would be critical. hand, if interns’ salaries increase, and the increased salaries are
Those doctoral training programs that wish to continue prepar- not matched by increased reimbursement, it could lead to a reduc-
ing their graduates for doctoral level direct service delivery (which tion in the number of internship positions available.
we would expect to be almost all programs, at least initially) would Although any change will bring with it a set of challenges
be extremely reluctant to make changes that would prevent their (eg., financial, political), we think the challenges should be
graduates from being well prepared to do so. They would therefore thought of as hurdles to be overcome and not as obstacles to
be extremely unlikely to implement our recommendation to make stand in the way. We are optimistic that an open process of dis-
internship post-doctoral unless the internship programs themselves cussion can lead to creative, successful solutions. We encourage
were willing to convert their predoctoral internships to postdoctoral all critical stakeholders—including (but not limited to) accredit-
internships. Although the only significant difference between the ing bodies, licensing boards, professional organizations, training
current predoctoral internship and the proposed postdoctoral intern- coalitions, and organizations that represent graduate students,
ship is that in the latter the doctoral degree would be granted prior doctoral training programs, and internships—to sponsor activ-
to beginning the internship (instead of it being granted at the con- ities evaluating the merits of our proposal, including, for exam-
clusion of the internship), it would ultimately be up to the intern- ple, conducting student surveys, commissioning a feasibility
ships to decide if they were willing to do so. assessment and a white paper on change management, or spon-
Doctoral training programs would also be extremely unlikely to soring a series of small conferences dedicated to the ideas out-
adopt our proposed changes if doing so were to adversely affect lined here. We also think there is a critical role to be played by
the ability of their graduates to obtain doctoral level licensure. organizations that represent consumers (such as the Anxiety and
Because the training of students pursuing careers delivering Depression Association of America, Mental Health America, and
the National Alliance on Mental Illness) as well as government prospective students can expect. It will also be valuable for doc-
agencies whose mission is to reduce mental health burdens (such toral programs (or at least organizations that represent them) to
as the National Institute of Mental Health and the Substance communicate directly with undergraduate advisors about changes
Abuse and Mental Health Services Administration) since ulti- in the field and steps prospective students could take to learn about
mately it is consumers and society as a whole that have the most their graduate school options. We would also hope that institutions
to gain or lose from changes (or the lack thereof). and training programs would allow more flexibility for students to
For the kinds of changes to the training of clinical psychologists receive training across different programs (e.g., a program that
that we think are necessary, it will take a combination of top-down specializes in dissemination and implementation could allow a stu-
and bottom-up efforts. Top-down changes (led by organizations dent who desired more exposure to policy training to do an
such as those referred to earlier, as well as others, such as the ‘exchange’ semester or practicum at a program with more of a pol-
Academy of Psychological Clinical Science [APCS], the Council icy focus).
of University Directors of Clinical Psychology [CUDCP], and the We have proposed momentous changes that will require a great
National Council of Schools and Programs of Professional Psy- deal of debate, refinement, and thoughtful reflection. Although this
chology [NCSPP]) will make it easier for programs to consider will take some time, we must keep in mind that the pursuit of per-
making the innovative bottom up changes that we think will ulti-

fection is the enemy of the good. Ultimately, we are optimistic

mately be most important. The path forward will ultimately be that the field of clinical psychology will have the desire, courage,
driven from the bottom up as well, including by students as a cen- and wisdom to move on from the status quo and instead make
tral driving force of what they want their training to include. A changes that enable clinical psychology to contribute significantly
useful historical example is the growth of the field of health psy- to reducing mental health burdens.
chology. Health psychology did not emerge as a vibrant subfield
of clinical psychology because it was spawned by a national orga-
nization. Rather, individual psychologists saw opportunities and References
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(Appendices follow)
Appendix A
Training Domains
Domain 1: Research Methods and Scientific methodological designs. As these designs become more com-
Epistemology plex, this may necessitate specialized training and even more
frequent collaborations with statisticians. It is critical, however,
Research methods and scientific epistemology are funda- that clinical psychologists are able to evaluate the statistical
mental activities of a clinical psychologist, regardless of their strength of a set of results and how to interpret those results
ultimate career choice. For instance, someone who trains or accordingly, to avoid problems that arise when scientific claims
supervises emerging clinicians will need to digest and synthe- go beyond the data available. This is in service of being a criti-
size the research literature on treatment outcomes and mecha- cal consumer of science, both within the field of psychological
nisms of change to provide training in evidence-based science, and across the many allied fields in which clinical psy-
approaches. Analogously, someone who works on dissemina- chologists may wish to collaborate.
tion and implementation of evidence-based approaches will

need a firm understanding of the scientific method to determine Domain 3: Ethics
best practices and evaluate their efforts. Thus, regardless of
Although ethics training is not new, what is likely to change
specific career path, this training is essential. is the nature of the ethical dilemmas faced by clinical psycholo-
Training in research methods should include a review of
gists. Also, although there will always be sets of written princi-
common research designs used in psychology. Because the ples, rules, and guidelines that clinical psychologists will need to
specific designs used will evolve over time, and their relevance be familiar with, as the ethical dilemmas we face become more
will vary across subfields of clinical psychology, we expect the complex, it will become increasingly important for training in
specific designs to be covered will vary from program to pro- ethics to be focused on the application of those principles, rules,
gram (and, ideally, from student to student). The topics that we and guidelines. Research is increasingly collaborative, interdisci-
expect to have the most lasting importance are: (a) discussion plinary, and geographically dispersed. Thus, whereas in the past,
of scientific values and practices, with an emphasis on open most ethical dilemmas in research concerned participants, look-
science practices that can promote replicability, such as sharing ing forward, many ethical dilemmas will concern collaborators.
data and preregistration (a focus not yet a part of most clinical In the past, most training in research ethics was very inward
psychology training programs); (b) hypothesis generation and looking—what do I need to do to protect my own research team
testing, including causal inference; (c) differences between and the participants in my research. Increasingly, however,
confirmatory versus exploratory approaches, and the value and attention is being paid to one’s obligations to the field (issues rel-
fit of each; and (d) consideration of common biases that often evant to replicability and the sharing of data, for example).
interfere with optimal research practices, like confirmation Given that we expect less and less of the applied work of clinical
biases, along with discussion of various forms of validity and psychologists to be in the form of direct client care, and that clin-
reliability and ways they influence design decisions. An impor- ical psychologists will increasingly play roles in supervision,
tant framework underlying this domain would be an emphasis administration, consultation, etc., we also anticipate changes in
on “epistemic humility” (humility regarding one's knowledge) the ethical dilemmas to be faced in these areas. Analogously,
—a rubric premised on the notion that we are all susceptible to ethical questions about when and how widely to disseminate
biases and that science is the best means of compensating for new services are going to come into focus as technology enables
them (Lilienfeld et al., 2017). wider dissemination more rapidly. More generally, new sets of
ethical dilemmas will also arise as proportionally fewer and
Domain 2: Data Science and Statistics fewer services are delivered one-to-one and face-to-face. The
current discussions about technology-based and non-specialist
Clinical psychologists, even those involved in direct client provider-based delivery models of care illustrate some of the
care, should be fluent in the process of data quality assurance many shifts in ethical challenges facing the discipline.
as well as how to manage and curate datasets for interpretation
by others. As the nature of data changes over time, so will the Domain 4: Diversity and Individual Differences
specifics of these tasks, but the same principles (that data
should be open and interpretable to as many people as possible) The practice of clinical psychology requires an understand-
will apply. Similarly, all clinical psychologists should be well ing of the many individual differences and demographic, cul-
versed in the statistical assumptions that underlie common tural, and contextual factors that influence human behavior.
(Appendices continue)
Diversity is a multifaceted construct encompassing differences basic science examining psychopathology into innovations in
both within groups and between groups—it refers to individual classification, prevention, intervention, dissemination, and
and social group differences including, but not limited to, implementation.
learning styles, life experiences, race, ethnicity, class, gender
identity, sexual orientation, age, country of origin, ability, and Domain 6: Assessment
health, as well as cultural, religious, political, and other affilia-
tions. Much of the current practice of clinical psychology takes Psychological assessment is a defining skill within clinical
an idiographic approach in that the individual person or case is psychology and meaningfully differentiates it from other men-
considered the unit of analysis; however, individuals can only tal health fields. Historically, relative to others interested in
be understood within the broader context of their lives and mental health, clinical psychologists have been particularly
socio-ecological factors (e.g., Bronfenbrenner, 1977). In addi- sensitive to issues such as instrumentation, psychometrics,
tion to its role in the direct provision of services, training in di- idiographic and nomothetic considerations, as well as scalabil-
versity and individual differences is critical for other core ity. Training in assessment will need to keep pace with, and be
activities of clinical psychologists, such as research, advocacy, influenced by, technological innovations and the exploding
availability of data. For example, in the future, assessment of
and implementation and dissemination of the science.

Importantly, the burden of mental health conditions is much suicide risk may depend as much, or more, on examination of
greater for some people, such as members of cultural or ethnic social media data as on clinical interviews. To successfully
minority groups, owing in part to disparities in health care. engage in public health promotion and the prevention of mental
Mental health disparities result from factors such as differential health conditions, clinical psychologists will need to be adept
access to mental health services (due to availability, stigma, at conducting assessments at multiple levels, ranging from
poverty, stereotyping, etc.), systematic racism, and lack of individuals to neighborhoods to macro, social systems.
services that are culturally appropriate for the population in
need. Clinical psychologists will be needed to develop, test, Domain 7: Intervention
and implement new, scalable models of prevention and treat-
Intervention is a broad umbrella category that includes mul-
ment delivery that are capable of reaching groups not well-
tiple topics tied to promoting evidence-based prevention and
served by the current delivery model (Kazdin, 2018, 2019).
treatment approaches. We argue that it is important for all
Furthermore, psychologists will play an increasingly important
future clinical psychologists, even those who will never pro-
role in shaping, advocating for, and evaluating mental health
vide direct client care after obtaining their doctoral degree, to
public policy that addresses the needs of our diverse popula-
obtain first-hand exposure to people experiencing the burdens
tion, all the while recognizing that science is not value free and
of mental health conditions and to the care they are receiving.
that racial color blindness has played a critical role in limiting
Also important is exposure to prevention and early intervention
the advancement of anti-racist policies and interventions across
psychological science. Regardless of the specific content cov- programs. Without experiencing the very real challenges that
ered in this domain, training approaches that consider intersec- arise when working with complex human beings and applying
tionality, community partnership, and strength-based (vs. knowledge in real-world settings, novel services are likely to
deficit) models will be important. fail when they are adopted outside the laboratory. Further, to
improve a system, it is important to first understand the
strengths and weaknesses of the existing system, or there is a
Domain 5: Psychopathology
serious risk of repeating past errors and hitting old barriers. A
If clinical psychologists are to contribute to the reduction of sophisticated understanding of the phenomena we study fol-
mental health burdens, they must be knowledgeable regarding lows from and is enriched by listening, observing, engaging,
the phenomenology, classification, epidemiology, etiology, and and partnering with persons with the lived experience. Direct
developmental course of psychopathology across the lifespan, exposure to people suffering from mental health conditions and
as well as the contributions of psychopathology to psychosocial to the services they are receiving is an excellent way to develop
and biological outcomes and impairment. Consistent with the empathy, understanding and insight, and as a result, an excel-
training foci outlined in this article, we contend that training in lent way to develop new hypotheses.
psychopathology should reflect foundational principles in psy- One critical component is training in the theories explain-
chological science, drawing heavily from theories and knowl- ing, empirical research supporting, and application of evi-
edge from typical development and allied psychological dence-based principles of behavior change. This approach is
disciplines (e.g., cognitive, developmental). Thus, we do not aligned with the principles of assessment described above as
prescribe a focus on any given specific content (e.g., well as with efforts to advance research and practice tied to
Diagnostic and Statistical Manual of Mental Disorders vs. transdiagnostic mechanisms of change. Also critical is training
Research Domain Criteria classification systems). Rather, rig- in the systematic collection, analysis, and application of data
orous training in psychopathology would introduce relevant for the purpose of monitoring progress (or lack thereof) and
theories and the scientific evidence base, and the limits thereof. intervention outcome. It would be important to ensure some ex-
Ultimately, clinical psychologists must learn how to translate posure to research and applied approaches across the lifespan.
As time goes on, it will be increasingly important to provide successfully collaborating in whatever professional roles they
training in the use of digital/mobile technologies for the purpose will play. To be able to lead and collaborate, clinical psycholo-
of intervention. We do not want to dictate a one-size-fits-all gists need to be able to communicate effectively with other clini-
model for the amount of practical training that should be cal psychologists, with other kinds of professionals, and with the
required, but we believe that exposure to diverse populations and general public. Although scholarly writing is likely to continue
settings is important to gain some appreciation for the variability to be important for many clinical psychologists, other forms of
in problem areas, delivery models, and challenges that can arise. communication (e.g., via blog, media, tweet) are likely to
become increasingly important.
Domain 8: Teaching/Training/Supervising/Mentoring
Domain 10: Background in Psychological Science
If clinical psychology is to significantly reduce mental health
burdens, it will be achieved by having an impact beyond the Clinical psychologists are, first and foremost, psycholo-
modest number of clients to whom we can directly provide serv- gists. What distinguishes clinical psychologists from profes-
ices. One way for clinical psychologists to increase their impact sionals with overlapping interests but whose training and
is to teach, train, supervise, and mentor others (including, but
background differs (e.g., psychiatrists, geneticists interested

not limited to, other aspiring or current clinical psychologists). in psychopathology) is that the work of clinical psycholo-
Across the larger mental health and public health landscape, one
gists is rooted in basic psychological science. We echo the
recent development that we anticipate will continue is the role of
clinical psychologists in program leadership positions (Baker, view expressed by Berenbaum and Shoham (2011) that “the
McFall, & Shoham, 2008). In this capacity, regardless of application of cutting edge theories and methods from areas
whether people work at Research 1 institutions as scientists or in outside of traditional clinical psychology will ultimately
community-based mental health as program directors, the men- enable psychologists to understand, validly assess, and suc-
toring, teaching, and supervising of others will remain key tasks cessfully modify the phenomena that are the subject of clini-
of the future. Increasingly, each of these domains has a body of cal psychology” (p. 23). We therefore believe it is critical
foundational knowledge and empirical evidence (e.g., Falender, that clinical psychologists receive training in fields of psy-
Burnes, & Ellis, 2013) that can, and we argue should, be taught chology outside of the clinical domain (e.g., social and de-
to clinical psychologists in training. velopmental psychology). However, we do not assume that
exposure to the same areas of basic psychology research (or
Domain 9: Leadership, Collaboration, and basic research in other disciplines) will be critical for every-
Communication one. Following Berenbaum and Shoham (2011), we argue
that “individualizing graduate students’ training experiences
Clinical psychologists will increasingly work with nonpsy- will be superior to a ‘one size fits all’ approach” (p. 28). To
chologists (e.g., paraprofessionals, social workers, physicians, be more specific, we argue that not all students should be
engineers and computer scientists, public policy analysts, law-
required to possess a common set of knowledge outside of
makers). To increase their impact, clinical psychologists must
learn to lead, to collaborate, and to communicate. To be effective clinical psychology. Clinical psychologists in training, and
leaders, clinical psychologists need skills in how to evolve their the programs training them, will need to determine which
own leadership style, develop a vision, build trust and respect areas of basic psychological science each individual student
with others, and inspire and motivate others to take part in their will need to develop expertise in to understand their clini-
vision in a unified manner. These skills are applicable to a myr- cally relevant phenomena of interest. Thus, what we are rec-
iad of leadership roles that trainees could encounter as professio- ommending is that each student considers basic research
nals—such as director of a clinic or treatment facility, clinical relevant to their area of discovery and career path, as
supervisor, principal investigator of a research lab, or professio- opposed to all students receiving the same exposure to broad
nal association board president. There is no reason to expect and general, non-clinical psychology areas. This approach
clinical psychologists to reduce mental health burdens on their
assumes that learning does not end after receipt of the doc-
own. Innovative, successful prevention and treatment programs
are likely to be interdisciplinary. Mental health research itself is toral degree; clearly, if someone switches their primary
becoming increasingly collaborative and interdisciplinary. research, teaching, or policy focus, different areas of basic
Cross-disciplinary collaborations are key to finding solutions to research will become important to learn. A lifelong learning
pressing, global-scale societal challenges (Knapp et al., 2015). model assumes that people will acquire the most relevant
Thus, it is critical to train clinical psychologists to be capable of up-to-date knowledge as they need it.
Appendix B
Comparison of Proposed Model With Current European Models
Other countries follow models that differ from those cur- psychotherapist, with another 3–5 years of specialized psycho-
rently employed in North America and that also differ from the therapy training required to sit for examination as a licensed
model we are proposing. In general, those in Western Europe specialized psychotherapist (in CBT, psychodynamic therapy,
tend to separate training in the sciences from preparation for or systemic therapy). Sweden requires five years of training in
clinical practice to a greater extent than is currently done in the a university program to become a psychologist, culminating in
United States. The United Kingdom differentiates between a a written master’s thesis and followed by a 1-year internship to
pure research doctorate in philosophy (PhD DPhil.), which is be board-certified and to qualify for independent practice sta-
almost exclusively focused on preparing students for a career tus. This is wholly separate from the 4 years of scientific train-
in scientific research (although topics researched may be ing culminating in a written thesis that is required for a
directly relevant to psychopathology or treatment), versus a
doctorate in psychology. One must have a master’s degree in

“Professional Doctorate” in clinical psychology (D.Clin.Psy.),
psychology (but not necessarily clinical training) to apply for a

which focuses more on preparing students for a career in clini- Ph.D. program.
cal practice and research, specifically in the clinical area. To the extent that there is a “European model” (there are
Typically, the D.Clin.Psy. requires a systematic literature differences across countries), it tends to allow for greater sepa-
review, a piece of research focused on the provision of serv- ration between scientific training and preparation for clinical
ices, and a piece of theoretically driven empirical research; practice in a manner that facilitates greater flexibility, but more
these are presented in the form of a portfolio or dissertation. separation than we favor. What the European models share
The U.K. Ph.D. D.Phil. requires no specific clinical training, with the North American approach is that nonresearch training
whereas the D.Clin.Psy. involves placements in a specified va- is focused almost entirely on direct client care. Currently, as far
riety of service delivery settings over the first two years (work-
as we are aware, there are no training models for doctoral level
ing age adults, children/adolescents, intellectual disability, and
clinical psychologists that are designed to train people to
older adults) and a full year elective placement in its third and
engage in the breadth of professional activities (such as mental
final year. In essence, the U.K. Ph.D. D.Phil. is more akin to
health policy analysis, directing clinics, programs, and agencies,
Ph.D. training programs in the United States (but without clini-
cal training), whereas the D.Clin.Psy. is more similar to the and implementing and disseminating programs/interventions)
Psy.D. training programs in the United States (but with more that will maximize the likelihood of clinical psychologists con-
training in the sciences and the required pieces of empirical tributing to significant reductions in mental health burdens.
research in the form of the dissertation).
The German model is currently undergoing change but will
most likely involve foundational training such as we describe
above at the Master’s level (with a 6-month clinical internship) Received January 12, 2021
that qualifies the student to sit for examination as a licensed Accepted January 20, 2021 n
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Accelerating the Rate of Progress in Reducing Mental Health Burdens:

Preprint · June 2020

Howard Berenbaum Kathleen W. Reardon

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Tammy Schuler Jessica L Hamilton

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Accelerating the Rate of Progress in Reducing Mental Health Burdens:

Department of Psychology, University of Arizona

Public Health Significance Statement

Keywords: clinical psychology, mental health burdens, training

professional activities, such as directing clinics, programs, and agen-

lect and analyze data as part of a quality improvement project for a

health conditions appear virtually unaffected by empirical advan-

The Proposal We propose that doctoral training in clinical psychology be

changes in the training of clinical psychologists who wish to focus

making the innovative bottom up changes that we think will ulti-

fection is the enemy of the good. Ultimately, we are optimistic

tion and implementation of evidence-based approaches will

and implementation and dissemination of the science.

background differs (e.g., psychiatrists, geneticists interested

doctorate in psychology. One must have a master’s degree in

psychology (but not necessarily clinical training) to apply for a

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