ACP-UK response to proposed standards of accreditation for new Clinical Associate Psychology role

  • Arabella Kurtz, Bernard Kat, Simon Mudie

  • March 2019

There is a proposal to develop a Clinical Associate Psychologist (CAP) role in England, and a working party has been set up to develop accreditation standards for Masters level training courses for this group. This group sits within the Committee on Training in Clinical Psychology (CTCP) in the British Psychological Society and is chaired by Ken Laidlaw and John Cape. It issued a set of draft accreditation standards for consultation and ACP-UK carried out a survey of member responses to the draft standards in order to produce a summary response. This appears below, followed by links to the draft standards, the briefing paper from the Division of Clinical Psychology and a list of Frequently Asked Questions about CAPs from the CTCP working party.

Response to the Proposed Standard for a Degree Apprenticeship for Clinical Associate Psychologists in England

The ACP-UK response to the proposed apprenticeship standard for the Clinical Associate Psychologist (CAP) role in England sits alongside the DCP UK response. We endorse all the comments they make. In preparation for our statement we carried out a survey of ACP-UK members, to which we received 113 responses. Although these were anonymous it was evident that many of our respondents had direct experiences of the Clinical Associate in Applied Psychology (CAAP) role in Scotland, either as CAAP practitioners or as colleagues and supervisors of CAAPS, and we are pleased to have been able to draw on these in our summary.

Our survey was undertaken before the publication of the Healthcare Apprenticeships document ‘Frequently Asked Questions (FAQs): Clinical Associate Psychologists (CAPs)’. We have taken the information in that document into account in preparing this document.

While ACP-UK survey respondents communicated a great deal of enthusiasm for the proposal and a desire to engage fully with its development, a degree of ambivalence was also expressed. This primarily concerned the question of where the CAP role as currently described fits into the group of psychology roles within the NHS and the knock-on effects for both service users and colleagues of rolling out plans which have not been properly thought through. In the words of a previous CAAP from Scotland:

‘Associate psychologists are a hugely helpful addition to the workforce, but the infrastructure and good will of the profession has to be in place first, otherwise we are creating an underpaid and undervalued workforce, or just creating a longer route to doctoral qualification.’ 

  1. Perspective from Simon Mudie, ACP-UK Director & Expert by Experience:

As an expert by experience, my view is that the general public have little understanding of the distinction between Clinical Psychologists and Psychiatrists, especially as both might be considered ‘Doctors of the mind’, and can work psychologically. The similar sounding Clinical Associate Psychologist muddies the water even further, although it does describe what such a practitioner does. I am also very concerned that the training pathway requires too many competencies to be gained from the amount of training time involved, and the possibility that CAPs may well be expected or asked to work outside of their level of expertise. Mental health practitioners are already around three times more likely than the general public to suffer from their own mental health difficulties, so from a workplace wellbeing perspective, too many demands to work without clear lines of Clinical Psychology supervision could place the CAP at risk in terms of their fitness to practice, and subsequently, raise questions around safety of the public using services.

I have been involved in the selection and training of Clinical Psychologists for ten years. I am concerned about a number of aspects of the CAP proposal, including but not limited to the following: Clinical Psychology applicants often seem to shape their career and educational pathways to fit a stereotypical applicant. There is a woeful lack of diversity in the profession as it is, and there is a risk of this unfortunate situation being perpetuated in creating a short-term role designed to embellish an application. Also, there appears to be little in the way of career progression on offer – a ‘dead end job’. Whilst CAPs may well be happy in their role, I note that the CAAP initiative in Scotland has a very low retention rate by comparison with Clinical Psychology. The CAP role is limited to a maximum band 7. I always like to see a built-in opportunity for progression in terms of pay and responsibility, thereby creating the right environment to promote a vested interest in personal and professional development. In turn, we would then potentially get a better trained, experienced, and more competent motivated workforce.

  1. Associates are a welcome addition to the psychology workforce & the value of being informed by successes in Scotland

The proposal provides the welcome opportunity to develop the skills of psychology graduates, described as a ‘HUGE untapped resource’ by one survey respondent, in order to grow the provision of high quality psychology services for the public. This is in line with the focus on the need to build mental health services in the recently issued NHS Long Term Plan. There are reports from Scotland which suggest that CAAPS are regarded as a very positive addition to the psychological workforce there, and that senior colleagues recognize that their work with groups and comparatively less complex cases has achieved good results.

We recommend investigation of the type of cases with which CAAPs in Scotland are working successfully and the service contexts for this, or publication of this research if it has already been undertaken, so we can learn from the Scottish experience in developing the CAP role in England.

  1. Scaling down & alignment with the 2006 benchmarking exercise

We agree with the first point of the DCP UK statement, which says that the list of duties, knowledge and skills in the draft apprenticeship standard is over-inclusive and should be reduced. Many of our survey respondents commented that too much is being expected of CAPs given the length of their training and the nature of the role. We are grateful to one respondent for alerting us to the fact that more work could be done to align the CAP standard with the 2006 benchmarking statement for Masters courses in Applied Psychology.

We recommend aligning the draft apprenticeship standard with the 2006 benchmarking statement for Masters courses in Applied Psychology, and reducing the duties, knowledge and skills of the CAP role according to suggestions made in the detailed response from DCP UK, thereby differentiating the CAP role more clearly from that of the Clinical Psychology role.

  1. Need to attend to the issue of career progression to avoid a new bottleneck

The concern expressed above by Simon Mudie about the lack of attention to career progression in the proposal was widely shared amongst respondents to our survey. ACP-UK is particularly keen to protect a group of talented and motivated young people from exploitation in the context of this development, and to give them a voice in a system in which they can feel powerless. At the moment, the risk is that the CAP role will be seen exclusively as a ‘stepping stone’ to the doctoral training in clinical psychology (indeed it is framed in this way in the draft apprenticeship standard), and this will mean that there will be rapid turnover of CAPs. This is not good for services and service users and will be a waste of the public money invested in their training. Related to this is the risk that those CAPs who do not get onto clinical psychology training courses will feel stuck and demoralized in posts for which there is no defined pathway or progression.  In addition, we hear that in Scotland the fact that CAAPs do not have protected professional titles (and related protection of their pay) has meant that some health boards will only employ CAPs in generic ‘mental health clinician’ posts at Agenda for Change (AfC) Band 6 with no obligation to provide supervision from a clinical psychologist, despite the fact that qualified CAAPs are meant to be employed at AfC Band 7 and receive supervision from a clinical psychologist. In the words of a former CAAP:

‘Having associate psychologists join the workforce makes complete sense when thinking about the need to develop a pyramid-shape applied psychology workforce, and increasing access to psychological therapies for the public.  However, the ambivalence around supporting CAAPs to become an HCPC registered profession, and in making room in the workforce for them on the correct banding is creating a dangerous bottle neck.’ 

From the employment perspective there needs to be a coherent and consistent approach to salaries. We note that when training CAPs in England are paid at AfC Band 5 by their employing Trust and when trained they will be paid at Band 6. Based on recent adverts Assistant Psychologists tend to be paid at AfC Band 4 and Higher Assistant Psychologists are paid at Band 5. Clinical Psychology trainees are paid at Band 6, moving to Band 7 on qualification. IAPT staff with training in therapies tend to be paid at Band 6 moving to Band 7 with experience. We think it unlikely that salaries confined to Band 6 will be sufficient to retain trained and experienced CAPs.

We recommend that the CAP role be reshaped as supportive of, and firmly integrated into, clinical psychology services, but with its own separate, if comparatively circumscribed, career and pay progression, so we can make ongoing use of talented and motivated psychology graduates who have much to offer but may not go on to train as clinical psychologists and so we can retain CAPs who do go onto train as clinical psychologists for more rather than less time.

  1. Need to attend to the question of regulation & protection of professional title

The draft apprenticeship standard contains an error in the section headed “This is a new occupation” in which it refers to “This new grade of practitioner psychologists …”. ‘Practitioner psychologist’ is a statutory protected title to which CAPs will currently not be entitled. It seems likely that without protected titles and without HCPC regulation CAPs will be vulnerable to the sort of mistreatment described above, expecting to be paid a certain amount and to be supervised by a clinical psychologist but this turning out not to be the case. Lack of accountability to a regulatory body in a role which is described in the draft apprenticeship standard as carrying with it ‘a high level of autonomy’ in clinical services also seems an undesirable state of affairs from the service user perspective. CAPs, unlike Assistant or Trainee Clinical Psychologists, will be qualified practitioners doing a large amount of work with vulnerable clients, and they need to be regulated, both for their protection and for the protection of the public.

We recommend that the issue of HCPC registration for CAPs be revisited, and in addition that the issue of protection for the title of Clinical Associate Psychologist or equivalent (see the next point) also be raised. ACP-UK would be keen to discuss a joint approach to HCPC concerning extensions to the current range of protected titles and the regulation of CAPs.

  1. Need for role clarification & differentiation

The role of the Clinical Associate Psychologist is not seen by our survey respondents as sufficiently distinct from that of a Band 7 Clinical Psychologist or an IAPT practitioner, and the title is not different enough from that of Clinical Psychologist. Members of the public already find it hard to distinguish between psychologists and psychotherapists of different types. As one survey respondent puts it:

‘the role description is virtually indistinct from a clinical psychologist’.

If this issue of role clarification and differentiation is not addressed there is widespread concern that we will only be increasing confusion amongst service users and members of the public about the training and expertise of different types of psychology practitioner, and that the professional identity of clinical psychologists will be weakened and CAPs will be employed as a cheap alternative to clinical psychologists. Of the 113 ACP-UK members who completed our survey 89 were concerned that CAPs would be recruited as a cheap alternative to clinical psychologists. As one respondent put it:

‘This role may further dilute the role of the profession in a system that already does not understand its unique contribution’.

We recommend that, as part of the consideration of the career pathway for this role, the title of Clinical Associate Psychologist be revisited. Associate Clinical Psychologist is a preliminary suggestion because it is easier to tell it apart from the title Clinical Psychologist.

  1. Supervision & Governance Arrangements

The proposal offers a welcome opportunity to ensure that CAPs are clearly part of clinical psychology services, with suitably qualified and experienced clinical psychologists taking responsibility for providing them with the necessary support, direct supervision and structures of governance. We were pleased to learn that in Cornwall, where this training is being piloted, the employing Trust has created new Clinical Psychology posts (at AfC 8a) to support the development and supervision of CAPs in the region.

There is broad agreement amongst our survey respondents that there is too little in the draft apprenticeship standard to specify the quantity and quality of the supervision CAPs receive, and the governance arrangements which should be in place to protect CAPs and ensure the quality of their work as psychologists. Of the 113 ACP-UK members who filled out our survey 88 were concerned that CAPs might be appointed with no reference or accountability to existing clinical psychologists.

We recommend that the draft apprenticeship standard specify that CAPs should get a minimum of an hour of protected supervision each week from a clinical psychologist. We also recommend that it be specified that supervisors of CAPs should receive training in their supervision, as distinct from the supervision of Trainee Clinical Psychologists, contributing to the strengthening of governance arrangements within the profession, and be at AfC Band 8a or above and therefore regarded as sufficiently experienced to support CAPs in their distinct role.

  1. More information about training requirements needed & request to increase number of days on placement

The training of CAPS should be more fully described in the draft apprenticeship standard in order to help people understand what the role is and what it is not; to ensure that CAPs are educated in keeping with the reflective scientist-practitioner model in clinical psychology and the core identity of our profession; and to give confidence that, although it is understood that CAPs will be trained to work with specific and varying problems and populations across the UK, transferable competencies will be enshrined in their training so that they are able to move jobs and progress in their careers.

We understand that the clinical requirement for the first CAPs Masters courses is 75 days on clinical placement. This is different from the Scottish Masters courses, which requires that trainees spend three to four days a week on placement over the course of a year. The lack of consistency in training requirements is unhelpful and, given the importance of time spent in supervised practice by a clinical psychologist for qualification to a highly skilled clinical role, this strikes us as a large underestimate of the time needed to develop the required competencies. 72 of the 113 respondents to our survey thought that this was too little time on clinical placement and that more is needed.

We recommend that the required time on clinical placement be increased during training to three days a week.

It is understood that CAPs are to be trained to work with specific problems and populations in response to local service need, and that this is the primary way to differentiate them from Clinical Psychologists who are trained over a lengthier period to work with a large variety of problems and populations. We welcome this differentiation between the two roles and think it makes complete sense. However, we think it is important that the principles

underlying the training of CAPs and the development of the taught component of the relevant Masters courses are in keeping with the core values and identity of the clinical psychology profession. This means that the courses should teach an individualized approach to the formulation of client problems, drawing on a range of therapeutic approaches and techniques, and informed by an up-to-date knowledge of research evidence and a reflexive approach to the development of relationships with clients and colleagues. As one respondent put it:

‘CAPs should not become a single model training scheme as the core of clinical psychology will be lost’.

 It is appreciated that exposure to a range of experiences and approaches will be considerably more limited than in clinical psychology training. However, we think it is important that it is there nevertheless and that this is specified in the draft apprenticeship standard.

We recommend that, as in clinical psychology training, CBT and one other key therapeutic model are taught to give CAPs flexibility and range in their clinical work.