Careers: Improving Opportunities

The government's Improving Access to Psychological Therapies (IAPT) initiative aims to vastly increase public access to evidence-based psychological therapies for depression and anxiety disorders. Over the next three years £306 million of earmarked funds have been made available to train and employ an extra 3600 psychological therapists.

The initiative recognises that only a small fraction of individuals with depression and anxiety disorders are offered psychological treatments, despite the fact that patient preference studies suggest a 2:1 ratio in favour of psychological therapies as against medication. The most obvious obstacle to improving access is the limited availability of appropriately trained therapists.

NICE guidance indicates that various types of cognitive behaviour therapy (CBT) have established efficacy in depression and all the anxiety disorders. In addition, couples therapy, interpersonal psychotherapy (IPT) and certain types of counselling have established efficacy for some (or all) severities of depression (but not for anxiety). All of these treatments should be available in the new IAPT services, but the training initiative initially focuses on CBT, because of its broad applicability and because the workforce shortage is particularly marked.

The guidance also suggests that for some conditions (mild to moderate depression, panic disorder, generalised anxiety disorder), high-intensity treatments (traditional one-to-one or group sessions with a highly qualified therapist) and low-intensity treatments (guided self-help, computerised CBT, psychoeducation groups, etc.) are both effective in some individuals. For other conditions (such as post-traumatic stress disorder) only high-intensity intervention is recommended.

What the services provide

With this in mind, the new IAPT services will follow a stepped-care model in which many patients are offered low-intensity treatment first, followed by a step up to high-intensity if they fail to recover with the lower step. This ensures that patients do not have to commit to more treatment than they need. Two national demonstration sites (Doncaster and Newham) have found that a substantial proportion of individuals with conditions for which NICE recommends low-intensity work benefit from this approach, but a fair number then need to be 'stepped up'. Risk issues and patient choice also play an important role here.

IAPT has distinctive features that are intended to make it easier for patients to access treatment. First, in a major revolution for the NHS, self-referral is permitted. This is partly due to Newham's finding that self-referral enables services to more accurately reflect the ethnic mix of their local population and also to treat some individuals with chronic conditions who have been have not been picked up in primary care. Second, patients will have a choice about where and when they can be seen. Much therapy will be available near where they live, often in primary care or similar locations, but many services will also have a central location that some patients may prefer. Some low-intensity work is also likely to be conducted on the telephone.

Work within the IAPT initiative

IAPT has distinctive features that are intended to make it a rewarding and exciting environment for the professionals who work in it. The IAPT services will all be led by experienced therapists. There is a strong emphasis on the availability of regular and supportive supervision for clinicians at all levels, as well as for professional and skill development.

A new session-by-session outcome monitoring system will help clinicians plan therapy sessions and identify those cases that respond particularly well and those where improvement is more limited. This will provide an ideal opportunity for reflective practice and new initiative service planning that further extends the therapeutic envelope. In this way, team members will be healthcare pioneers. Finally, the career structure of IAPT covers the full range of Agenda for Change (AfC) grades that are relevant for psychologists, starting with bands 4 and 5 for low-intensity workers, moving to bands 7, 8a-b for high intensity workers at various levels of experience and supervisory/managerial responsibility and finally band 9 for the leaders of some particularly large services.

Opportunities 

The IAPT programme starts in September. It is a multidisciplinary initiative. However, by virtue of their distinctive training and experience psychologists are ideally suited to play a central role. Psychology graduatesPsychology graduates are well positioned to apply for the new low-intensity worker training posts that are being advertised now. These opportunities are similar to existing psychology assistant and graduate worker posts, and would provide suitable experience for those wishing to go on and train as a clinical or counselling psychologist.

However, for the first time IAPT services will offer a longer-term career pathway for psychology graduates. They can continue to work within the service providing low-intensity psychological interventions, with future options for career progression either in supervising and managing other low-intensity practitioners or going on to train as a high-intensity therapist. The low-intensity training will follow a national curriculum and involves one day a week on a postgraduate certificate course for a year, with the rest of the week spent working with supervision in the new services. Given the competition to gain a place on applied psychology postgraduate programmes, we believe that IAPT provides greater opportunities for the 15,000 or so psychology graduates who enter the job market each year.

Recently qualified clinical and counselling psychologists

Newly qualified psychologists can build on their existing training by applying for the new high-intensity training and therapist posts. These are permanent appointments. In the first year, two days a week will involve further training on a postgraduate diploma course in a higher education institution. This training will follow a national curriculum that allows you to build on your existing therapeutic skills to become expert at the latest evidence-based CBT programmes for depression and each of the anxiety disorders. The rest of the week will be spent working in the new IAPT services, with excellent supervision opportunities. On successful completion of the first year, a full-time position in the service is available. We believe that as IAPT services expand over the next few years, a variety of career options will develop for suitably qualified therapists within both the NHS, the third sector and from private psychological therapy providers. Therapists with the skills required by IAPT will be in short supply, so the services of newly qualified staff who are prepared to continue their training for a further year will be at a premium.

Already qualified and experienced staff

Finally, more experienced clinical and counselling psychologists may be well suited to immediate appointment as experienced high-intensity therapists, supervisors and service leaders. There will also be exciting opportunities for top-up training, local 'master classes' and supervision training, as well as opportunities for staff to train part-time on IAPT courses using Assessment of Prior Learning/Assessment of Prior Experiential Learning (APL/APEL) procedures. We hope that The Psychologist will become a major shop window for these roles.

The Society's role

The Society has been supporting the IAPT programme through the publication of a Good Practice Guide to IAPT which resulted from the New Ways of Working for Applied Psychology project jointly sponsored by the Society and Care Service Improvement Partnership (www.bps.org.uk/nwow).

Future initiatives include helping postgraduate training courses in applied psychology identify more clearly the therapeutic competences acquired by their graduates. The Society is also engaged in helping already qualified psychologists to demonstrate and extend their competences in psychological therapies through developing specialist registers and targeted CPD.

More information

Full details of the initiative can be found in the National Implementation Plan and other associated documents that can be downloaded from tinyurl.com/5978fx.

- Professor Graham Turpin is Director of the Clinical Psychology Unit, University of Sheffield; he is seconded to the Society's Division of Clinical Psychology as Director of the Professional Standards Unit, and to the Care Services Improvement Partnership as Associate Director for Workforce for IAPT

- Professor David M. Clark is at the Institute of Psychiatry, King's College London and Clinical Adviser to the Department of Health for the IAPT Programme

Mind and body

Matthew Keane looks at nursing as a career choice for psychology graduates.

In my experience, psychology and nursing share many common attributes: both disciplines are perceived as arts rather than sciences, but anyone with experience of either will know this is a false perception. Both areas are self-deprecating and team-driven. Creative insight and reflective practice are essential components to gain knowledge from experience. Both demand evidence-based practice. To a graduate of either, the opportunities presented by the one and the skills provided by the other are a perfect union.  

The journey
I graduated from South Bank University in 1999 with a psychology major. I then discovered that the career opportunities provided by psychology are both its greatest asset and its greatest problem. Psychology opens up limitless possibilities, not only within health care.

My degree course taught me to critique research arguments and opinions, formulate and test hypotheses and statistically analyse results. Writing a research dissertation provides the ability to structure arguments and express them in writing but these are, perhaps, more academic skills. I developed more specialised interests in cognition and neuropsychology and therefore in the anatomical sciences.

Successful graduates have a huge range of transferable skills in areas such as communication, debate and innovation. Despite all this I was on the brink of working life, no closer to knowing how best to apply this diverse skill set.

Relating to the media
In the end I decided to enter media relations in the not-for-profit sector. I was able to put transferable skills to good use and continue to study part-time, dipping randomly into postgraduate subjects that interested me. During the day I wrote press statements and liaised with journalists and editors, all the while building a list of contacts. More than a few times I had to rush around with a camera and a pad, grabbing the next 'scoop' that would advance the cause of clients. I even worked with a couple of political parties. For the most part, I was a communications bridge between people, used mostly when a disagreement arose. 

Deciding on nursing
Six years down the line I was hungry for a career that was mentally stimulating, physically challenging and would teach me tangible, generalisable skills. I also needed the security of knowing that there was a career pathway beyond university that I did not need to spend years studying to achieve. The healthcare sector seemed to meet these needs, and adult nursing was top of the list. Nurses are hugely influential within health care, particularly in public health policy. Many senior hospital managers started their careers as nurses. Nursing also opens up opportunities in higher education and research. Mostly I chose this pathway because of the respect everyone – including me – has for nurses.

The only decision left was where to study. I settled on City University London St Bartholomew's School of Nursing and Midwifery. It is attached to a number of Centres of Excellence such as the Royal London Hospital and has a global reputation for producing the best. Adult, mental health and child health nursing are currently studied as independent programmes. I felt that my previous experience of psychology would make me a more rounded practitioner.

Psychology is an allied health subject so the postgraduate diploma programme was the best option. The course is accelerated – I qualify nine months earlier and will have the benefit of having been assessed at master's level. The course is task-oriented and there are lots of formal clinical assessments. These take some getting used to since I was accustomed to being judged on essays.

Psychology has a very individual focus, which helps with holistic care, but hinders you when you are managing the care of six patients and you get lost in the detail. Having said that, much of my knowledge and experience has real value – on the ward,  I have relied more on my psychology knowledge than on anything else.

With advances in multidisciplinary team working nurses have become the managers of patient care in all environments and are lead members of many departments. To meet the challenges this presents, we have frequently had the opportunity to work with fellow professionals in training. Within weeks I was having biology lectures with medicine and dentistry students followed by team working sessions in the afternoon. I was on clinical placement long before the medics and dentists. We often train in teams with child and mental health student nurses as well as social workers. This shared pool of knowledge helps inform our practice and cement mutual respect relationships between the professions. We also get to practise together on the patient simulator, which helps add a sense of realism to our learning.

My time is divided between placements, intensive rounds of lectures and clinical skills teaching and management modules. Placements can last up to 13 weeks. You experience nursing in a variety of specialist areas and get the chance to put theory into practice. Placements are rigorous, and a hospital ward at a Centre of Excellence is a demanding environment. There is more reward than sacrifice though.

As a student nurse I live for patient contact time: unspoken moments when only you and the patient recognise that your care made all the difference. A degree in psychology helps me apply a more holistic approach to assessment. For example, I cared for a confused patient who was not eating properly and nobody could work out why. I discovered by spending some time talking to her that it was just that she needed her false teeth!

I have communication skills that a lot of qualified nurses do not have, and communication is everything in modern health care. Coping with tragedies like a patient dying is helped by my prior knowledge of psychosocial theory. However it is possible to empathise too much with the individual, and this is mentally draining. It's all part of a steep learning curve.

Future plans
Although career options remain diverse this no longer presents a problem. Continuing professional development guarantees you enter the training pathway that is right for you. As nurse retention has been a problem in the past, mentors ensure that from the very start you get the support you need.  Nursing will soon become an all-graduate profession and it is an exciting time to be part of this evolution. I hope to complete my master's within the year and get two years' experience in the hospital environment. Then I will apply for charge nurse positions. I then want to train to become a district nurse and work within the community and public health policy.

Looking back, my experiences of the past nine years have taught me a great deal; most of all being responsive to change. The degree allows me to be exactly that. Thanks to studying nursing I now have tangible, realisable goals and – above all – job satisfaction.

Caledonian road to health

Dougie Marks discusses a new Scottish route to qualification in health psychology

Health psychology is one of the fastest-growing divisions of applied psychology in the UK. However, until recently, the career path to qualification in health psychology in Scotland was not always clear. To become fully trained, prospective candidates had to fulfil competency requirements while working in other full-time jobs, often a PhD course. This route frequently presented difficulties, and juggling Stage 2 qualification with the demands of a full-time post is difficult. The creation of government-funded Stage 2 professional doctorate training courses in four different Scottish health boards has changed things hugely.

In January I began working in one of these posts in Ayrshire and Arran. I had completed my Stage 1 MSc at Stirling University in September last year and spent several years working in assistant psychologist jobs in the NHS. The post involves building up experience in the four key competencies (generic professional, research, consultancy, and teaching and training competences) in health psychology. This experience is acquired through working on projects that were outlined by the health boards when they bid for the posts. I'm involved with two specific projects.

Binge drinking amongst young adults is increasingly common in Ayrshire, as in other parts of the UK. This has serious long-term health effects. The first project involves investigating how psychological factors, particularly resilience, contribute to binge-drinking behaviour. We plan to investigate this by running a series of focus groups in local colleges, asking students what factors they feel influence student drinking. In addition, we'll use questionnaires about drinking habits, as well as using a number of psychological constructs, including the 'Big Five' personality model, sensation seeking, anxiety, and depression. We hope to highlight psychological differences between binge-drinkers and non binge-drinkers.

I am also interested in how social norms and self-efficacy influence binge drinking, so we are including questions that look at these issues within the context of the theory of planned behaviour. The aim of the project is to provide a degree of consultancy, and possibly teaching and training, to those who are working within alcohol services locally. The second project involves investigating how health professionals' attitudes affect patient health. Breastfeeding rates among teenage mothers are typically reported as lower than among older mothers.

One possible reason for this is the way in which breastfeeding is promoted to these mothers by staff, both antenatally and postnatally. Again, it is thought that professionals' attitudes may be influenced by perceived social norms. To this end, I plan to use the theory of planned behaviour as a model to design focus groups with health professionals to investigate how their attitudes are shaped, and how they influence breastfeeding promotion. Eventually, the information gathered from this will be used to design staff training programmes.

The skills gained through this training process promise to be broad. They offer the chance to work with a variety of different agencies, to apply psychological knowledge at a population level and to see our own research impacting practically on the health service. These are exciting prospects.

This kind of health psychology post differs from clinical psychology traineeships in some important ways. A major difference between my post and other applied psychologists working in the Ayrshire is that (in addition to having health psychology supervision) I am primarily managed through the public health department. This enables me to work alongside other colleagues with varying specialities to a far greater extent than other psychology professionals. It also gives a chance for health psychologists to bridge the gap between public health and psychological services.

One current downside to health psychology trainee posts is the lack of any real patient contact within training. Currently, there is no component of the training that requires health psychologists to develop their one-to-one patient skills. This is a real issue for the profession, as many future trainees may, like myself, have a background in actual patient contact. There is a danger that health psychology trainees will become de-skilled in this area, and possibly lose therapeutic intervention skills they have acquired from previous posts, through lack of practice. Many undergraduate students choose psychology because they enjoy the contact with patients, helping them through their difficulties. Of course, many see this one-to-one work as more suited to clinical rather than health psychologists. But health psychologists must be able to work at the individual level, as part of the range of skills needed within the NHS.

This aside, the prospect of a new, structured training scheme for health psychologists is an exciting development for all Psychologists working within the NHS, and one which I for one, will enjoy seeing develop over the next few years.