How ‘CAPs’ can bridge the gap between Assistant to Clinical Psychologist

It's Monday morning and I'm attending a referrals meeting with the Community Mental Health Team (CMHT). A 19-year-old female has been referred for secondary care psychological support by her GP. She is presenting with suicidal ideation, emotion dysregulation and traits of personality disorder. As a Clinical Associate Psychologist (CAP) trainee, I have the skills and training to provide both administrative and clinical support. I discuss the client's difficulties with the GP, as well as collating clinical information from various NHS systems. Then I discuss the case with my clinical supervisor, a qualified Clinical Psychologist, and we agree to make a referral to the Dialectical Behavioural Therapy (DBT) team. It has a waiting list of around twelve months, but as I am completing an integrated masters alongside my NHS placement, I am able to offer the client 6-10 sessions of protocolised therapeutic support working closely with my supervisor, starting within the next month. The clinical work will go beyond the remit of my previous role as an Assistant Psychologist; it will focus on emotion regulation tools and risk stabilisation.

As a psychology graduate, making sense of the clinical psychology workforce within the NHS can be challenging. The NHS Five Year Forward View called for a transformation of services for people with complex psychological needs seen in secondary care mental health services. Greater access to quality care for those with moderate to severe mental health difficulties was advised in community and inpatient settings. The plan also called for more patient choice in care and a reduction in waiting times. With an increased need for psychologically informed practice within CMHTs, there has been an equal need to develop new roles in psychology.

Clinical populations

The CAP role is designed to support this transformation. Introduced in 2005 by NHS Scotland, my CAP cohort is one of the first to be established in England. CAPs are psychology graduates who study for an integrated masters while completing training with participating NHS Trusts. The role aims to fill an identified gap between Assistant Psychologists and qualified Clinical Psychologists, providing high quality, evidence-based psychological support within the community.

It aims to do this in several ways; firstly, CAPs work with one specific population – unlike Assistant Psychologists who may work with a range of mental health difficulties. This could be clients with difficulties such as personality disorder, psychosis or eating disorders. By working with one population over an 18-month apprenticeship, CAPs can gain valuable clinical experience, applying theoretical knowledge in areas such as psychological assessment and interventions. Services most in need of an increased psychology provision can apply for CAP funding, allowing them to expand and develop – and reduce waiting times.

Alternative route

Secondly, CAPs use a range of skills within clinical populations; delivering protocolised assessments, using evidence-based tools and brief therapeutic interventions. The CAP's role is therefore more prescribed than an Assistant Psychologist role may be. This differs from the work of a Clinical Psychologist as they may deliver specific modalities of therapy and work with clients over a longer time. The clinical responsibility for CAP work will also ultimately be held by their supervisors and teams.

Thirdly, CAPs are supervised by qualified Clinical Psychologists. Each year, around 4000 psychology graduates apply to the clinical psychology training programmes, with a 15 per cent success rate. The CAP role provides an alternative route to clinical work. As this is an apprenticeship, it allows psychology graduates with less clinical experience to carry out work in a supervised environment, while receiving training and developing valuable clinical skills.

I started as one of five CAPs working in my Trust in January 2021, following two years as an Assistant Psychologist in a London IAPT (Improving Access to Psychological Therapies) service and a Psychological Wellbeing Practitioner (PWP), after my degree. My typical day starts with a CMHT morning meeting with care coordinators, psychiatrists, nurses and other clinical staff. Our role as CAPs is to develop plans for psychological support. We are also able to relay information from other psychology services, such as the Mentalisation Based Therapy team or the Trauma Therapy pathway, as psychologists from these teams may not be present. By becoming integrated within the CMHTs, we are able to ensure clients can access appropriate psychological support. Overall, we aim to provide a clear overview of the psychological support offered within the Trust, and create links between care coordinators and psychology services.

Streamlining referrals

CAPs act as a central 'hub' for psychological support, so following this morning meeting, I process referrals, complete screening notes and discuss routes into the psychology pathway with my supervisor. For example, if a client's screening notes indicate that they are self-harming and have difficulties with emotion regulation, I might ask the care coordinator to complete a referral to the Dialectical Behavioural Therapy team. Another client may have difficulties relating to their housing situation, so I may send them signposting resources and explain that for now, we would not advise a psychology referral. Alongside these tasks, I will be writing protocols for future CAPs so that as the role becomes more established within the Trust, it can be performed as effectively as possible. By ensuring that knowledge is shared with care coordinators, referrals can be streamlined, and information provided to clients in a more efficient way.

A typical afternoon may include clinical work in a one-to-one, or group setting. In my service, we work primarily with clients with personality disorder. We deliver evidence-based interventions focused primarily on emotion regulation and self-harm reduction. The clinical work may involve a psychological assessment during the initial stages of treatment, where I will develop a psychological formulation which can then inform treatment. These sessions provide strategies for clients to manage their conditions and move towards recovery, while being supported by their local community team.

As part of the apprenticeship, CAPs attend university for two days a week. Our lectures focus on areas such as psychological assessment, formulation, psychological interventions for common and severe mental health difficulties and community psychology approaches. We participate in clinical and reflective practice seminars with CAPs from other NHS Foundation Trusts, learning about different approaches to working in Secondary Care Mental Health settings. We also attend tripartite meetings with our university personal tutors and our Trust supervisors where we receive feedback.

Academic opportunities

An exciting part of the job is helping to shape the CAP role, as one of the first intakes in England. We meet with service leads to provide feedback to the university and Trust in order to inform and implement changes within the community teams. Because the role is new, it can be frustrating when there is resistance to change. It will inevitably take several years for the CAP role to become established within teams. If we were able to fast-forward to 2025, I would hope to see the CAPs having a clearly defined role within the transformed CMHTs, where all team members understand which tasks a CAP can carry out, and the psychological care is fully integrated. One key area of learning for me has been to be patient with change implementation, especially while working in well-established community teams.

The academic opportunities provided by the CAP course also represent a hugely positive area. The CAP course tutors are doctoral Clinical Psychologists with broad experience. The course tutors are open and eager to take on feedback and make changes to the course as it progresses. Although the course provides an excellent theoretical foundation - balancing clinical work and university coursework can be challenging. As a psychology graduate this is an important skill needed for many postgraduate courses. Understanding new statistical software and ensuring we are boundaried with our study time is something which can be difficult and takes time to develop. On the CAP course, we are assessed by methods including coursework essays, clinical reports and assessed audio recordings of clinical assessment and therapy sessions. Overall, developing the skills to produce high-quality work in these areas will be valuable as we continue to work in psychological service.

Our clinical work itself can also be both rewarding and challenging, particularly during the current period. As we started working during the Covid-19 pandemic, we have had to meet colleagues virtually using Microsoft Teams and complete clinical sessions on the telephone. Although we are primarily working with individuals with personality disorder, there are often a range of difficulties which present. For example, a client may be presenting with traits of Emotionally Unstable Personality Disorder (EUPD), while also restricting their food intake. Working in a trans-diagnostic way is often more helpful when working with complex needs. For this individual, discussing a group intervention which targets symptoms of EUPD, while also making a referral to the Eating Disorder service may be necessary. Working jointly with psychologists from different teams is something we hope to do more of as the role progresses. However, working collaboratively is often time-consuming and complicated. If clinician timetables do not match, or teams have different referral criteria, a client may feel confused by the different areas of the service. Ensuring that teams are communicating effectively is something which is not always optimised within NHS Trusts, and is a key area for development.

Overall, my first nine months as a CAP has been hugely rewarding. Over the next two years, we hope to develop the CAP role as it becomes more established within the NHS. We are eager to help shape a career pathway for the role and look forward to implementing changes within teams.

Isabel Sherman is a CAP working in South London and Maudsley NHS Foundation Trust and studying at University College London.

If you are interested in becoming a CAP, you can learn more about the role. Applicants are likely expected to hold a minimum of a second-class Batchelor's degree in psychology accredited by the British Psychological Society. In addition, applicants for the programme are required to be nominated by an NHS trust. Interviews are conducted by the trust leads and supervising Psychologists. Gaining clinical experience through other roles within the NHS and third sector organisations can help prepare clinicians for the application process.