William N. Robiner, PhD, and John A. Yozwiak, PhD
Albeit neither a glamorous nor simple topic, the psychology workforce concerns all psychologists- whether or not they realize it. The state of the psychology workforce affects the working environment and marketplace for clinicians, researchers, and educators now, and in coming years, will affect the vitality of the profession. This article focuses on the clinical or applied professional psychology workforce referred to as health service psychologists.
Setting the Stage
A recent New York Times Magazine article written by a master’s level therapist grapples with changes in psychotherapy utilization (Gottlieb, 2012). She cites Katherine Nordal, Ph.D., who wrote a 2010 Perspective on Practice column, “Where Has All The Psychotherapy Gone?” In it Dr. Nordal notes decreasing use of psychotherapy and corresponding increase in medication usage.
“... therapists had to start paying attention to what the marketplace demanded or we risked our livelihoods. It wasn’t long before I learned that an entirely new specialized industry had cropped up: Branding consultants for therapists.”
Reaching out to a branding consultant she was told that,
“I shouldn’t feel bad about my empty hours [in her schedule]; nowadays, she said, even established veterans were struggling. Yes, the economy was bad but the real issue was that psychotherapy had an image problem. ….Nobody wants to buy therapy anymore...”
It is unclear how extensive the decrement is in psychotherapy services that Nordal and Gottlieb lament and how much of it is due to decreased need for psychological services. After all, a glance at news headlines suggests there is no shortage of distress and despair in what can often appear to be a frightening and irrational world. Nordal cited data from the Medical Expenditure Panel Surveys: The percentage of Americans who obtain outpatient psychotherapy has been fairly steady over the past two decades: 3.24% in 1987, 3.37% in 1998, and 3.18% in 2007 (Olfson & Marcus, 2010). However, between 1998 and 2007 the percentage of individuals obtaining outpatient mental health care who were treated with psychotherapy exclusively decreased from 15.9% to 10.5%, and those getting combined psychotherapy and medication decreased from 40.0% to 32.1%, yielding a 13.3% decrease from 55.9% to 42.6% in the percentage engaging in psychotherapy. By contrast, medication-only treatment for mental health problems increased by 13.5%. In financial terms, this change yielded a net decrease of $3.77 billion spent on psychotherapy between these two periods. During that same period, psychoactive medication use increased from 127.2 million prescription fills in 1998 to 248.8 million prescription fills in 2007 (Substance Abuse and Mental Health Services Administration ([SAMHSA], 2012, p. 57). In 1998, adult psychoactive medication expenditures were an estimated $10 billion. By 2008, estimated psychoactive medication costs were about $25 billion (SAMHSA, 2012, p. 56).
So What is Going On?
Psychologists having incompletely filled schedules likely reflects many factors including: (a) increased use of psychoactive medications; (b) health care organizations managing services through utilization reviews and constraints in benefits; (c) increase in costs of healthcare and reluctance to pay for services; (d) an imbalance between the growing supply of psychotherapists (i.e., psychologists and master’s and doctoral therapists from other disciplines) and the demand for their services, i.e., an oversupply fueling competition among them.
It also reflects distribution problems such as a misalignment between psychologists’ location for delivering services (e.g., urban, suburban; private offices) and the locations where patients may be (e.g., rural) and where they may need to obtain services (e.g., organized health care settings). In addition, it can reflect long-term problems such as populations being underserved (e.g., poor, homeless, minorities, children, and geriatric populations) due to complex issues and psychologists not sufficiently capitalizing on opportunities to offer services (e.g., such as dealing with obesity and medical regimen adherence) that are unquestionably needed and increasingly recognized, valued, and reimbursed in healthcare.
A more sanguine alternative perspective to Gottlieb’s view is that there may be a shortage rather than a surplus of mental health professionals. Thomas, Ellis, Konrad, Holzer, and Morrissey (2009) examined the distribution and availability of several types of mental health professionals at the county level across the United States. Virtually every county (96%) had unmet needs for psychiatrists. There was also a poor distribution of “non-prescribing” mental health professionals, as well as a shortage in nearly one in five counties (18%). The real nature of the shortage of psychologists could be even greater than this estimate, as the “non-prescriber” category also included other mental health professionals (e.g., advanced practice psychiatric nurses, marriage and family therapists, and social workers). Moreover, health industry employment has increased and is projected to continue expanding (Keckley & Coughlin, 2012), which potentially suggests increased opportunities for psychologists.
So which is it? Are there too many (Robiner & Crew, 2000; Robiner, Ax, Hudnall Stamm, & Harowski, 2002) or too few psychologists (Peterson & Rodolfa, 2000; Pion, 1991)?
More than two decades ago, the first author called for a national psychology human resource agenda (Robiner, 1991). Several authors responded (Pion, 1991; Schneider, 1991; VandenBos, DeLeon, and Belar, 1991). For example, VandenBos, et al. estimated a need for 35-40 psychologists/100,000 population. Shortly thereafter, Cummings (1996) made the dire prediction that 50% of doctoral psychologists would be out of practice between 2000 and 2005. Whereas his prediction has not been realized, there have been challenges to earnings as anecdotally discussed by Gottlieb (2012) as well as for some academic jobs (Wicherski, Mulvey, Hart & Kohout, 2011, Table 28).
Since the call for a workforce analysis and agenda (Robiner, 1991), remarkably little has changed in either (a) our understanding of the alignment between the psychology workforce and the need or demand for psychologists’ services or (b) the profession’s ability to adjust or regulate supply to match demand. Unmet mental health needs and the inequitable distribution of mental health professionals still cry out for a comprehensive workforce plan to remedy disconnects between potential patients who need but cannot readily access psychological services and psychologists whose livelihoods depend on providing services to more patients.
Who Can Help?
APA Center for Workforce Studies
APA has played a key role in shedding light on diverse elements of the psychology workforce through multiple surveys (Michalski & Kohout, 2011). The APA Office of Research was restructured in 2006 as the Center for Workforce Studies (CWS). CWS is tasked with collecting, analyzing, and disseminating information relevant to psychology’s labor force and educational system. Although data are available about the psychology workforce on the CWS website, such as snapshots of the APA membership and subgroups of psychologists, a more comprehensive picture of the workforce is needed.
The CWS (2010) survey of 1,246 of the 2009 graduates of psychology doctoral programs presents a generally hopeful view of early career psychologists’ employment: 63% are full-time, 7.5% are part-time, 23.8% serve as postdoctoral fellows, but only 3.9% were unemployed seeking employment, with another 1.8% unemployed, but not seeking employment (CWS, 2011). The CWS (2010) survey of health service providers revealed 67.7% employed fulltime, 24.7% employed part-time, .7% unemployed seeking work, and .6% unemployed, not seeking work. Such surveys present partial views. Albeit informative, they do not constitute a comprehensive analysis and they have not yielded meaningful proposals to plan for balancing supply and demand.
The APA Task Force on Work Force Analysis in Psychology (BEA) and other entities within APA recognize workforce challenges and have wrestled with how to address them. CWS is currently seeking a Director to provide leadership and direction. At this point, it remains to be seen how effective CWS will be in analyzing the workforce and how effective the profession will be in developing policies and procedures for enhancing, supporting, and titrating the psychology workforce.
Bureau of Labor Statistics
Human capital is the most valuable asset of any profession. That is why the U.S. Bureau of Labor Statistics (BLS) has the mission to collect, process, analyze, and disseminate essential statistical data across occupations. How well the workforce in any region is balanced between the supply of available workers (e.g., psychologists) and the demand for their services affects the opportunities for individuals in those job classes. Unfortunately, BLS counts master’s and doctoral level psychologists together, so it is difficult to get a clear picture of the number of U.S. doctoral psychologists.
Table 1 provides data from the 2010 BLS Occupational Outlook Handbook. The data are helpful in placing the number of psychologists in a broader context of the number of mental health professionals. Based on BLS data, NYCWS (2006) estimated that there were 96,420 psychologists in 2004. The analysis revealed 14 states and the District of Columbia met or exceeded 40 psychologists/100,000 population; 4 more exceed 35/100,000. In other words, 18 states had reached the level that VandenBos et al. (1991) speculated would be where need “might be adequately met”. The national mean was 33.52/100,000, rapidly approaching that level across the country.
Other Estimates of the Number of Psychologists and of Demand
Other reports about the mental health workforce provide estimates of the psychology and broader mental health workforce (Duffy et al., 2004; Robiner, 2006). Estimates of the number of psychologists vary based on sample, methodology, and definitional issues. For example, Robiner and Crew (2000) estimated there were 89,514 licensed psychologists in 1995 based on a survey of psychology licensing boards. This yielded a national mean of 33.56 psychologists/100,000. By then a third of states had reached VandenBos et al.’s (1991) estimate (i.e., 35/100,000) of the lower threshold of demand being met (i.e., above which would be oversaturation). Duffy et al. in 2002 estimated there were 88,491 clinically trained psychologists based on data supplied by the APA and ASPPB. Given that approximately 6,000 applicants take the licensing examination in psychology each year (includes master’s and doctoral level), one would expect an increase in the seven years interim unless the number leaving the field offsets that increase.
What Are We Facing Now?
Internship Supply and Demand
The imbalance in the educational pipeline between the number of applicants applying for internship and the number who can be matched to the available training slots is considered a crisis by some. Table 2 reveals these statistics from the Association of Psychology Postdoctoral and Internship Centers (APPIC) for 1999 through 2013. The data reveal woefully high numbers of applicants outstripping the number of positions offered. In 2012 the number of applicants exceeded the number of training positions by 1,041, or 24% and this year 957 applicants failed to match. The number of intern positions grew by 28% during that period, but the number of applicants participating in the match outpaced this increase (39%). The sobering reality was that in each year for a decade 20% - 25% of applicants have not matched. Whereas 10,746 applicants did not match during this period, a proportion of them presumably ultimately got an internship outside of the match. These numbers are not known.
The misalignment comes into focus when looking at the year-to-year changes. Over a 14-year period, the correlation between the change in applicants and the change in unmatched applicants was highly significant (r = .74, p = .002). By contrast the year-to-year growth in the number of applicants was not correlated with the change in internship positions (r = .06, n.s.). Such data highlight the need to better balance the supply of applicants with the number of internship positions.
Whereas the imbalance between the supply of training positions and the demand for them is not a precise indicator of the workforce supply and demand for health service psychologists, many of the economic, regulatory, demographic, and other factors that affect the availability of positions and work opportunities are shared. This issue has garnered considerable attention, such as the 2007 special issue of Training and Education in Professional Psychology. However, despite the attention, this matter has rightfully garnered (e.g., the 1997 Supply and Demand Conference [Pederson et al., 1998; Grus, McCutcheon, & Berry, 2011; Baker, McCutcheon, & Keilin, 2007; McCutcheon, 2011]), and the multifactoral efforts APPIC has made to address it, the trend continues. Comments from 1,076 students who participated in the 2011 APPIC Match address the financial and professional implications of the imbalance (APPIC, 2012).
How best to manage the internship imbalance has been a topic of spirited debate. Recently, Hatcher (2011) discussed the crisis between internship applicants and training slots as a matter of management of common-pool resources through the lens of the “tragedy of the commons” first articulated by a mathematician in 1833 (Hardin, 1968). It is a conceptualization that derives from consideration of how herdsmen deal with the shared resource of a common grazing area. A predictable, albeit complicated, problem emerges when individual objectives (i.e., to maximize profit by enlarging one’s own herd) ultimately collide with overgrazing of the finite resources in that area, which inevitably result in ruin for the collective herd and herdsmen. Hardin discusses the solution as social arrangements based on recognition of the necessity of preserving that resource, even if reforms are not universally appreciated, and may be against the short-term interests of some stakeholders. Hatcher (2011a, 2011b) recognizes the necessity of the profession actively managing its growth. Larkin (2011) expands on the contingencies driving current training levels in doctoral programs and discusses the importance of committing to reforms in the training pipeline, including the option of reduced enrollments in doctoral programs in professional psychology, despite inevitable legal challenges that might result from such initiatives (McGrath, 2011).
The profession’s failure to resolve the internship imbalance has resulted in desperate attempts for students to seek alternatives, such as pursuing internships that are neither accredited nor APPIC member internships. Whereas such training experiences may be sufficient for graduates to meet licensure requirements in some jurisdictions, unfortunately, it circumvents psychology’s key quality assurance mechanism in graduate education. Such workarounds limit those students’ professional options (e.g., excluded from employment in the VA system). At a macro level, the trend undermines psychology’s standing among other professions and its practitioners’ perceived legitimacy in the eyes of payers and consumers. At a time that measures of quality in healthcare are at a premium (Bobbitt, Cate, Beardsley, Azocar, & McCulloch, 2012) the large numbers of students completing unaccredited internships is a spectacular breach of the profession’s primary educational quality control system. It presents an enormous public relations problem for the profession. The lack of accredited training for significant numbers of psychology graduates may undermine the profession’s capacity to advance other healthcare and scientific agendas because the profession is perceived as unable to provide adequate assurance of the quality of its graduates’ education and training.
How closely the internship imbalance mirrors broader conditions of supply and demand for the health service psychologist workforce is not known, but it clearly deserves attention. It is particularly pertinent to the employment conditions that early career psychologists encounter. The question of whether there is a parallel “commons” in healthcare (i.e. finite magnitude of psychological services that will be reimbursed within the healthcare system) to Hatcher’s discussion of the commons in the internship imbalance merits consideration.
Various factors such as state licensing requirements and skills portability, interstate and intrastate differences in training programs, workforce aging, and lifestyle factors can affect workforce participation (Keckley & Couglin, 2012). Regional epidemiology and other demographics as well as training opportunities and economics also influence demand for psychological services and affect how capable the workforce is for meeting that demand. Various methodologies exist for estimating demand for health professionals, including needs-based models, demand-utilization models, socio-demographic or trends models, requirements models, and benchmarking models (see Keckley & Couglin, 2012). Gap analysis can then explore where, in what ways, and in what numbers professionals can better meet identified needs (Rozensky, Grus, Belar, Nelson, & Kohout, 2007).
An interdisciplinary national workforce plan for addressing shortages across sectors of the behavioral health workforce has been proposed (Hoge et al., 2009). An action plan was developed by the Annapolis Coalition on the Behavioral Health Workforce (Hoge et al., 2007) with input from a dozen expert panels to address “a crisis regarding the nation’s behavioral health workforce” including:
- Difficulty finding or recruiting interested or qualified providers
- Difficulty retaining employees
- An aging workforce
- A lack of providers qualified to care for children, adolescents, and the elderly
- Severe shortages of behavioral health providers in rural America
- Absence of training in management and leadership skills for the next generation of leaders in this field
The plan consists of seven goals, including three targeted goals for strengthening the workforce: using systematic recruitment and retention strategies at the federal, state, and local level; increasing the relevance, effectiveness, and accessibility of training and education; and promoting leadership development among all segments of the workforce (Hoge et al., 2009), elements which could guide the development of a workforce plan for psychology.
It is not clear whether organized psychology has the will and discipline necessary to follow a workforce plan. Psychology lacks a clear view, or accounting, of its own overall workforce and sector-specific workforces (e.g., health service psychologists) partly because psychology has failed to take periodic snapshots of the field. This makes it hard to be informed of the current situation and precludes being proactive in addressing future circumstances. It also hinders meaningful communication to students about the potential opportunities and challenges that they might anticipate if they choose to enter the field. Whereas, Robiner and Crew (2001) discussed the benefits of systematic, periodic tracking of data about licensees from psychology boards to promote better understanding of the supply of psychologists, thus far, no system has been developed or implemented to monitor this vital sign of the health of the psychologist workforce.
Looking Beyond Workforce Numbers
As Keckley and Couglin (2012) point out, the critical question to ask is how stakeholders can ensure that there are enough providers with the appropriate skill sets to care for people who need care in the right place at the right time? This question is as germane to psychology as it is to other healthcare disciplines. Its answer will necessarily evolve over time as the population ages, as assessment strategies, treatment options, and the healthcare system change, and as public preferences and financial trends unfold.
One of the key growing trends in healthcare is the integration of mental health services with other health services. The Patient Protection and Affordable Care Act (2010) is designed to achieve multiple goals including increasing patient access (i.e., reducing the number of uninsured), improving health outcomes, and making care more affordable. A fundamental way in which healthcare is being transformed is the increased focus on interprofessional and institutional practice that is based on integrated services that are team-based, such as medical homes and primary care settings (Rozensky, 2011, Belar, 2012). This is likely to require providers to be technologically connected, such as via a shared electronic health record (EHR). In addition, payment models may be redesigned from current fee-for-service models such that future services may be remunerated to the healthcare teams in Accountable Care Organizations (ACOs) or primary care teams, rather than to individuals, and will be based on meeting quality metrics rather than being based on the sheer volume of services provided. Indeed, recent data from the United States Department of Health and Human Services indicate that there are currently more than 220 ACOs (Muhlestein, Croshaw, Merrill, Peña, 2012).
Given these transformations, how is psychology readying itself for team-based care? Psychologists are obtaining training in primary care through internships and postdoctoral training. According to the APPIC Directory, of the 710 APPIC-member internships, 134 (18.9%) offer major training in primary care and 277 (39%) offer minor training experiences in primary care. Of the 152 APPIC-member postdoctoral fellowships, 63 (41%) offer training in primary care. Additional data about training in primary care is available through the APA Education Directorate . It provides more granular information about the 32 doctoral programs, 57 internships, and 63 postdoctoral fellowships offering training in primary care psychology. Such training in primary care psychology suggests that some psychologists-in-training are developing skills needed for the evolving health services environment. In addition, programs such as the Center for Integrated Primary Care at the University of Massachusetts Medical School provide opportunities for training. Its certificate program in Primary Care Behavioral Health has trained approximately five hundred professionals since its inception (A. Blount, personal communication, February 16, 2013).
A venue of increasing importance for psychologists to practice in is community health centers (CHCs), which are comprehensive clinics serving low income and underserved communities funded by the Health Resources and Services Administration (HRSA). This program has expanded recently with $11 billion provided by the Affordable Care Act and $2 billion provided by the American Recovery and Reinvestment Act. In 2011, CHCs served 20.2 million patients in 1,128 organizations (i.e., grantees) with over 8,500 sites. Data from HRSA is consistent with the notion that training psychologists to provide services in primary care may best prepare them for entrance into an evolving workforce. In 2007, an estimated 527,173 patients in CHCs utilized mental health services and 90,570 patients used substance abuse services. By 2011 932,950 patients sought mental health services and 105,084 patients utilized substance abuse services, an increase of 43.4% and 13.8% respectively (United Stated Department of Health and Human Services, 2011). This increase in utilization was accompanied by an increase in staffing. In 2008, the total psychologist FTEs in CHCs was 279.5 (with 291,172 clinic visits), and in 2011 the psychologist FTEs was 403.05 (with 456,818 clinic visits) – an increase of 30.1%. The data demonstrate increased utilization of mental health services in these settings over a five-year period, coupled with a small, but growing number of licensed clinical psychologists. The data suggest an even higher rate of staffing will be required to keep pace with the increase in utilization of mental health services. Although CHCs may not have been traditional settings for psychological services, it is imperative that psychologists capitalize on opportunities to practice in CHCs given their mission and growing importance in the healthcare system.
Another organized healthcare setting that has shown dramatic increases in psychologist employment is the Department of Veterans Affairs healthcare system. The VA has been the largest employer of psychologists for decades. In recent years, the VA psychologist workforce has expanded significantly to address growing recognition of the mental health needs of returning veterans. There was a 120% increase from the 1,685 psychologists in 2005 to 3,709 psychologists in 2011 (APA Practice Directorate, 2011).
The psychology workforce has been an increasing concern while efforts to evaluate the workforce have been discouraging. As the “common pool” of the demand for psychological services comes into sharper focus through more sophisticated health care metrics and pinpointing of demographic trends that affect it, is incumbent on the profession to make a more concerted effort to find the resources to do what is necessary to manage and steward the workforce.
Some steps outlined earlier (Robiner 1991; Robiner & Crew 2000, 2001) continue to merit consideration and implementation. At this point we recommend, at minimum, the following actions:
1. Encourage psychologists to adapt to a changing healthcare environment by stepping outside of their current comfort zones and exploring how to become more fully integrated in evolving healthcare delivery systems. For psychologists to be positioned where they will have the most opportunities for themselves and where they can leverage their services to benefit the most people who need their services, they likely will need to work in settings with shared electronic health records where they can work interprofessionally with other health professionals. The profession needs to develop mechanisms for tracking how well psychologists are integrating with other health professionals and to develop pathways to facilitate psychologists aligning and integrating more fully with the rest of the healthcare system.
2. Tallies of the psychology workforce should be routinely taken through periodic surveys (e.g., every 5 years; Robiner & Crew 2001). Ideally, these could be conducted conjointly by ASPPB and CWS. Given the authors’ failed effort a few years ago to complete a survey of U.S. psychology boards due to noncompliance by nearly a third of the state psychology boards, the involvement of ASPPB and CWS seems essential to develop an ongoing monitoring system of licensed psychologists. A promising venture by CWS and ASPPB funded by the Health Resources and Services Administration’s (HRSA) Bureau of the Health Professions (BHPr), involves developing a national data set about psychologists. BHPr is in the process of expanding its health workforce data collection and analysis activities generally to enable workforce planning.
3. The profession (i.e., APA) should contract with an outside entity to conduct an analysis of the psychology workforce given its own problems doing so over the past two decades. When the Council on Medical Education sought a comprehensive review of American medical education, it looked to the Carnegie Foundation to sponsor a review, which resulted in the Flexner Report at the turn of the 20th century that transformed medical education and recommended a decrease in the annual number of medical school graduates. Psychology could tap into the technical and policy expertise of organizations such as the National Center for Health Workforce Analysis of the Health Resources and Services Administration, the Association of American Medical Colleges Center for Workforce Studies, the Pew Center for the Health Professions, or The Center for Health Workforce Studies (CHWS) of the School of Public Health at the State University of New York to undertake a comprehensive analysis of the psychology workforce. The National Academy of Sciences recently helped the American Veterinary Medical Association undertake such a workforce analysis for veterinary medicine which revealed that there were not significant shortages of veterinarians (Segal, 2013). A credible workforce analysis could yield specific recommendations that would be a major step toward developing and implementing strategies that enhance the workforce. Such an approach could minimize political resistance by stakeholders within the profession (such as within APA or various training councils, large training programs) as well as limit the risk of antitrust or other legal challenges.
4. Psychologists should be encouraged and incentivized to work toward meeting the psychological and behavioral health needs of currently underserved populations (e.g., rural communities, inner cities, children, geriatics, seriously and persistently mentally ill, substance abuse, etc.). When underserved populations exist at the same time that some psychologists are less busy than they would like to be, motivating psychologists to expand their services and creating mechanisms for linking them to those patients are warranted (e.g., telehealth; employment or part-time consultation in underserved areas).
5. Since data disseminated through the BLS Occupational Outlook Handbook are used by students and guidance counselors in evaluating career options, modifying how BLS counts psychologists would make it more useful. We recommend that APA formally request that BLS split the current psychologist category into two distinct categories respectively for doctoral psychologists and master’s practitioners. This would allow for more fine-grained, ongoing analysis of the profession and would enhance longitudinal tracking at essentially no cost to the profession.
6. The training community and professional organizations should create a culture of shared responsibility within the profession to match education and training levels across the time continuum of graduate education (i.e., to assure that all psychology doctoral students secure accredited internships). We do not believe that the focus can exclusively be on increasing the demand for psychologists’ services, that is to foster more work and training opportunities, but optimizing the workforce to meet demand also must address responsible mechanisms for titrating supply (Robiner et al., 2002). The internship data in the last 20 years confirms that a market (i.e., under-regulated) approach alone has not worked. Instead, it has resulted in considerable financial peril to students interested in becoming psychologists. There are also some signs it has contributed to market saturation which creates adverse conditions in the commons of opportunities and earnings for health service psychologists.
7. The profession has an obligation to better understand what happens to unmatched internship applicants. Tracking their ultimate training history, employment, and career trajectory would increase insights into the consequences of the imbalance. Such tracking also could elucidate the financial impact of their education (i.e., magnitude of their debt). Such information could then be made available as part of “truth in advertising” to students considering applying to graduate programs to provide a fuller picture of the spectrum of potential outcomes of pursuing training so as to enable them to make truly informed choices.
William N. Robiner received his PhD from Washington University in St. Louis Missouri in 1981. He completed his fellowship at Hennepin County Medical Center, Department of Psychiatry. Since 1985, Dr. Robiner has been a faculty member of University of Minnesota. In 2011, Dr. Robiner was inducted into the University of Minnesota Academic Health Center Academy of Excellence in the Scholarship of Teaching and Learning. Dr. Robiner has been credentialed by the National Register since 1991, and was awarded the 2012 Alfred M. Wellner Distinguished Career Award.
John A. Yozwiak received his PhD in Clinical Psychology from the University of Kentucky in 2003. He completed his internship in Clinical Psychology in the Department of Psychiatry at the University of Wisconsin School of Medicine and Public Health, and a two-year postdoctoral fellowship in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine. Presently, he is an Assistant Professor in the Division of Adolescent Medicine in the Department of Pediatrics at the University of Kentucky College of Medicine.
The authors gratefully acknowledge the support and contributions of Drs. Robert Ax, Sharon Berry, and Judy Hall who reviewed earlier drafts of this article and provided valuable feedback that improved it. The authors, however, assume full responsibility for the content and opinions expressed.
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