Matchmaker, Matchmaker, Is There Really No Match?

Monday was “Match Day.” Too many ended it unhitched.

“I’ve done everything that I need to prepare. I did a broad geographic search, found sites that fit my interests really well. I applied to 15 sites…I got nine interview offers,” said Mark Gapen, a fifth-year clinical psychology Ph.D. student at Emory University. Gapen is one of 743 doctoral students who learned that he'd struck out in the annual standardized internship “match” sponsored by the Association of Psychology Postdoctoral and Internship Centers (APPIC). Even considering the 309 positions unfilled in the computerized matching process, the demand for required, year-long predoctoral psychology internships again dramatically outstripped supply.

“I’m just left feeling that there’s something fundamentally wrong with the system. In that, here I am, in graduate school, working to get my Ph.D., and yet my graduate school is not able to provide me the training that I need in order to get that degree. A portion of the training needed to get the degree is not under the control of the school to which I go,” Gapen said. He's currently applying for internship programs listed in the APPIC "clearinghouse" -- the database for unfilled positions left over after the match -- and working with faculty at Emory to see if he might be able to find another opportunity for an American Psychological Association (APA)-accredited internship, a requirement of his program, outside of the standardized process.

“If I’m not able to work something out, I basically have to give up a year of my life to do this all over again,” he said. “With where I’m at in my training, I don’t feel like that should be the case. I feel like it’s a sacrifice due to – I don’t know how to say it – the vagaries of the numbers.”

In the computerized matching process, applicants and internship providers alike rank their top choices after completing interviews. The number of applicants increased by 61 this year to an all-time high of 3,759. Also a record, 3,058 positions were available, 174 more than the year before. The number of unmatched applicants this year, at 743, is the second-highest ever, second only to last year’s 842.

“The only reason it was improved this year is, for whatever reason, the profession was able to create 170-something new positions,” said Greg Keilin, the APPIC match and clearinghouse coordinator and associate director of the Counseling and Mental Health Center at the University of Texas at Austin.

To say it’s better than last year “is technically accurate,” Keilin said -- but "we’re still in really bad shape.”

“The main concerns are that you’re bringing students into a system that can’t handle them. You’re telling 500 students a year, ‘Sorry, too bad, we can’t accommodate you, try again next year,' when people have invested incredible amounts of time and money into their training.”

Why the dramatic differences in applicants versus internships? The problem is swelling in recent years but is not new. Identified as early as the mid-'90s, it seems to have many roots. On the demand side, there’s been a dramatic increase in professionally oriented psychology programs. Some of them are for-profit, and some accept large classes. An article Keilin co-authored on the “Growing Bottleneck” analyzing 2007's record internship mismatch -- which appeared in a special issue of Training and Education in Professional Psychology devoted to this topic last year -- stated that while the number of internship applicants in Ph.D. programs increased by only 77 from 1999 to 2007, the number enrolled in more practice-oriented Psy.D. degrees increased by more than 450, from 1,021 to 1,473. (According to 2007 data, Psy.D. students match at a lower rate than their peers in Ph.D. programs.)

On the supply side, financial barriers are among the concerns. All internships accredited by the APA are expected to provide stipends to their interns. (And while they're generally small in size, so are many mental health providers' budgets.) In the past, the sponsoring organizations could typically get reimbursed by insurance companies for time an intern spent with a patient, said Jeff Baker, also a co-author of the “Growing Bottleneck” article and training director for a post-doctoral program at the University of Texas Medical Branch at Galveston.

“But, over the last 10, 15 years, insurance, third-party payers have pretty well come to a standard that you need to be licensed" (as most students, by definition, aren’t) to be reimbursed. “Which is not a bad thing, but it’s kind of caught the training programs."

And unlike in medical education, where federal funds used to offset the cost of residency training are in excess of $4 billion, graduate education in psychology only receives $1.8 million in federal funding, Baker said. (Baker, who’s also chair of the APA’s accrediting commission, cautioned that he was not speaking in that capacity. He also cautioned that he’s not advocating that funding for medical education be decreased in order to pay for desired increased investments in psychology training).

"It's not exactly a simple problem," he said. "People are trying to make it simple but it's more complex."

Last year’s applicant survey found that 530 of 949 unplaced applicants (those who either were not matched or withdrew) were subsequently able to find positions -- even though only 296 positions were unfilled at the end of the match. That so many students secured positions either not included in the standardized match or subsequently created has fueled concerns about quality control and whether, despite the efforts of APA and APPIC, market forces will mean that more graduate students will end up accepting unpaid spots (as is already happening in large numbers in California).

“Although many unmatched students appear to be quite determined and resourceful in finding and securing internship positions after the Match is completed, these students are often placed in nonaccredited and/or non-APPIC programs,” the “Growing Bottleneck” article notes. “Thus, these students are not only attending internship programs of unknown quality but also have an increased risk of experiencing future credentialing or employment difficulties.”

“Of particular concern,” the article notes, are “the dramatic increase in the number of applicants who reported that their doctoral programs were willing to compromise their standards” relative to what internships are acceptable, and the “large rise” in students who reported they were able to create their own internship on short notice where no program existed previously.

Philinda Smith Hutchings, a professor and director of the brand-new Psy.D. program at Midwestern University, in Glendale, Ariz., said she believes that in addition to funding shortages for training, another source of the problem “is a disconnect between the doctoral programs and the internship training programs."

“It’s a rather odd situation. But internships, that year of supervised practice, are a requirement within the doctoral program, but the doctoral program doesn’t provide the experience. It’s provided somewhere else.”

Doctoral programs “should be more involved in creating and supporting internship training," Hutchings said. She argued that universities should consider both creating internship opportunities specifically for their students -- to be offered outside the profession-wide matching process -- in addition to working with potential internship providers to create more options for applicants nationally.

She said there’s also a need for innovation in internship sites, as outlined in a 2007 article she co-wrote as a representative of the National Council of Schools and Programs of Professional Psychology. “University counseling centers are the most common internship centers, followed by Community Mental Health Centers and VA [veterans' affairs] hospitals,” the article states. “Even though the majority of mental health services are now provided in primary care settings, and jails are described as the new equivalent of psychiatric hospitals, there are few internships in primary care or correctional institutions.”

As for the APA’s role in all this, the association, for one, is looking for answers to a critical question. If there aren’t enough internships available, does that suggest there aren’t enough jobs? Are programs producing too many psychologists?

All experts consulted Tuesday said the answer to that is unclear. The APA is currently studying the issue. “What we need to do is we need to do a thorough work force analysis, much as other professions have done, to inform the discipline as well as the public about what are the work force needs,” said Catherine Grus, APA’s associate executive director for professional education and training.

Also, starting in January 2007, all doctoral programs were required to make detailed information about internship placement rates publicly available as a condition of APA accreditation. “We want to have this information available to prospective students,” Grus said.

“There’s pretty much always been a discrepancy" between internships offered and internships sought, she added. The association held a conference on the imbalance back in 1997.

"It’s just gotten so large in the last couple years that it can’t be ignored by the large masses.”

Especially not the (smaller but still relatively large) masses looking desperately for internship placements the day after Match Day. In response to a request for comments sent to an APPIC e-mail list Tuesday, two students from the same institution, Indiana University of Pennsylvania, separately reported that half of the students in their Psy.D. program weren’t placed in the matching process. (The listed director of doctoral studies there did not respond to a request for comment late Tuesday afternoon. However, both students stressed the program's strong reputation as evidence of a national problem in internship placements. According to the university's published statistics, 16 of 18 students in the program were placed on APPIC's Match Day last year; the year before, 10 of 11).

“It’s wait and see,” one unplaced student at Indiana University of Pennsylvania, who asked not to be named, said in a phone interview. “It’s pretty much getting these e-mails and waiting, doing a lot of self-care, allowing my friends to cook dinner for me, or force me to watch a movie with the laptop in front of me” -- keeping an eye out for open internship opportunities in APPIC's clearinghouse but also for those that close so as to prevent any more precious time wasted. On Monday, the student received an e-mail indicating that a job position listed on the clearinghouse was filled within 67 minutes of the database first coming online.

“I definitely think the huge imbalance between internship positions and applicants is attributable to my current situation,” Sabera Sobhan, a counseling psychology student at the University of Houston, wrote in an e-mail. Unmatched, Sobhan had 10 interviews over the course of the search.

“I am in no doubt that there were a lot of great candidates that did not match and are going to have to go through this process again next year, as traumatic as it seems at this moment.”