‘Systematic disadvantage can accumulate, and prevent access to the profession’

After the 2015 announcement that bursaries for nurses and others would be stopped, Professor Tony Lavender (Canterbury Christ Church University), and other members of the British Psychological Society's Division of Clinical Psychology (DCP), set up a review group to respond in case the same decision was made for clinical psychology trainees. They worked out that if clinical psychology doctoral students had their salaries stopped, their cumulative debt at the end of undergrad and postgrad training would be around £150,000.

A review by Health Education England (HEE) into clinical psychology doctoral salary support was eventually undertaken in 2018/19. Dr Jan Hughes (University of Leeds), Lavender and his colleagues, including Chair of the DCP Dr Esther Cohen-Tovee, worked with HEE to present arguments for maintaining the funding, including ensuring the supply of clinical psychologists at a time when the NHS Long Term Plan for England set out the need to expand the psychological workforce.

It was announced in January 2020 that salaries for clinical psychology doctoral trainees would remain in place, and their fees would still be paid by HEE. Around the same time Lavender and his group, alongside other psychological professional bodies, pushed for an increase in training places to meet the need identified in the NHS Long Term Plan for England. This summer HEE announced that clinical psychology doctoral places in England would be increased by 25 per cent – or an additional 137 places.

Lavender said this announcement came just in time. 'The final date when courses had to let people know whether or not they got places was 12 June, and many applicants to training were on reserve lists. So the courses were able to quite quickly offer places to grateful applicants. That was quite joyous – it's not the easiest thing to do to get into clinical training.'

In some of the devolved nations similar increases are also being seen; in Wales there are two courses in Cardiff and Bangor and for 2020-2021 there were an extra two places funded, bringing the total number of places to 29. In Northern Ireland, after many years of decreases, numbers have been rising in recent years; however, it has yet to be confirmed whether this year will see an increase.  

Professor Nichola Rooney, Chair of the DCP Northern Ireland, tells me training place numbers are much lower per head of population than the rest of the UK. 'This is despite 25 per cent higher rates of psychological ill health morbidity in Northern Ireland and higher levels of suicide, largely related to the trauma of the "Troubles". We do not have IAPT here and there are long waiting lists (18 months to two years) to access psychological therapies in some Trusts. As a professional organisation, we are calling for increased training funding and parity with the rest of the UK.' Some good news arrived in August with the commissioning of four additional training places on the postgraduate Doctorate in Clinical Psychology programme delivered through Queen's University Belfast, to increase the annual intake from 15 places in 2019/20 to 19 places in 2020/21. Swann said 'it will be vital to ensure that we have the right mix of skills and professions to create a first class mental health service that meets the needs of our community. Increasing psychology training places is a key step forward.'

Although the situation in Scotland is similar, in that there has been an 18.6 per cent increase in the annual intake of clinical psychology training places from 59 to 70, Judy Thomson (NHS Education for Scotland Director of Training for Psychology Services) told me there have also been increases in related training routes for psychology graduates that lead to qualification as Clinical Associates in Applied Psychology. Two MSc level courses, one in Applied Psychology for Children and Young People and another in Psychological Therapy in Primary Care, have also seen increases in the number of places.

Thomson's role, which includes supplying the psychology workforce for the NHS in Scotland and upscaling the wider psychological care workforce, has led to the development of close working relationships with the Scottish government colleagues – particularly in mental health – as well as with Heads of Psychology Services (HOPS) across the Scottish NHS. 'Having good, close and collaborative relationships with the government and all NHS Scotland psychology services is definitely helpful in that psychology begins to develop a reputation for actually being able to deliver on agreed expansion. One of the things which is different in psychology to perhaps some other disciplines, is that it's relatively easy for us to expand… there is no shortage of suitable applicants for training. That has been helpful in terms of responding to emerging priorities and pressures.'

Some of those priorities include a drive to improve services in perinatal and infant mental health, access to CAMHS and to better support adults with anxiety and depression. The MSc in Psychological Therapies in Primary Care, which is open to psychology graduates, trains students in cognitive behavioural therapy for helping adults with anxiety and depression. 'In terms of the unmet need those are the most common presentations in terms of adult mental health.

And there's huge areas of unmet need, so there's been support for expansion there.' The MSc in Applied Psychology for Children and Young People gives trainees similar competencies to the Primary Care course but with a greater focus on younger age groups, parenting and family interventions.  

Clinical Psychologist Dr Vasiliki Stamatopoulou (Barnet, Enfield and Haringey NHS Mental Health Trust) and trainee Clinical Psychologist Runa Dawood (Camden and Islington NHS Foundation Trust) are co-chairs of the Division of Clinical Psychology (DCP) Minorities in Clinical Psychology Sub-Committee. While they were pleased that there will be a 25 per cent increase in clinical psychology training places in England they told me that courses needed to consider how to actively target recruitment of a more diverse set of trainees.

Dawood said that BPS Vice President David Murphy's recent research into clearing house data shows that issues of representation occurred at the screening phase of recruitment; many courses would use those extra places to recruit from reserve lists, likely reducing the proportion of applicants with protected characteristics. 'Courses need to think hard about how they can implement different strategies in their recruitment process. The wider profession can support by supporting applicants from minority backgrounds in pre-training experiences and mentorship. Peers can support their colleagues by offering support and committing to making work and study places a fair and non-discriminatory place to be.'

Since the minorities group was founded eight years ago by Guilaine Kinouani its members have held application and interview preparation events and community meetings, supported people through online forums, presented work at conferences and held their own annual conference, as well as creating their own publications and publishing open letters advocating for issues around the shortlisting process of clinical psychology doctorate courses.

However, Stamatopoulou tells me, the barriers for marginalised groups entering the profession go much deeper than many people consider. 'The background of psychology has historically benefited privileged groups and oppressed marginalised groups. We see that both in who is in the profession and who are the service users. In terms of barriers, from our experience and research there are several. Some examples would be lack of paid posts to gain experience before applying which would disadvantage people of low economic backgrounds; very low numbers of Black qualified psychologists, therefore not much visible representation; lack of diversity on interview panels; the very few places offered and the competitive nature of the whole process, as well as the lack of safe spaces during training and post-training.'

Dawood and Stamatopoulou have been supporting a research project exploring the facilitators and barriers to clinical psychology training, which was developed and is currently being led by third-year trainees Julie Baah and Dr Samantha Rennalls (both Camden and Islington NHS Foundation Trust) – supervised by Dr Kat Alcock. Baah and Rennalls have collected the experiences of more than 1000 clinical psychology doctorate applicants.  

Rennals, who is also the DCP Minorities in Clinical Psychology Race and Culture lead, has co-founded the Black Clinical Psychologists Network (BCPN) with two trainees Kassmin Tong and Ashley Peart, which holds events to support Black clinical psychology trainees.

To get to the heart of clinical psychology's lack of diversity Rennalls said we need to consider a range of factors such as disparities in educational attainment and the financial implications of getting onto a doctoral course through completing a Master's degree first, the lack of access to important networks, and the fact an expectation of free work exists in clinical psychology and can improve someone's chances of gaining a place on a doctoral course.

'What we can see from just these three things alone is how systematic disadvantage can accumulate over time and prevent access to the profession. This isn't even the full picture. To do a full analysis of this, we need to think broader than just what's happening at the point of entry to clinical psychology training, look at this at a regional level to see how the barriers vary by location. We also need to stop considering this as a homogenous "BAME" issue and explore the barriers faced by people from more specifically defined groups… a "BAME" approach can mask and distort the issues that people face, and make it much more difficult to address them in a targeted fashion.'

I asked Rennalls what support for clinical psychologists, trainees and doctorate applicants would look like in an ideal world. Among other things she suggested acknowledging the problem of a lack of racial diversity, without explaining away those issues, focus the narrative on making the system more equal rather than 'letting more BAME people in', increasing transparency and accountability in the profession – including having publicly-available data on diversity, and to stop using the BAME acronym as it can be misleadingly homogenising.

She added: 'The "new normal" for the profession should be co-developed with people from minoritised groups at all levels. Course staff should be equipped to adopt an anti-racist approach and do the work associated with that and courses should be better prepared to have people from Black, Asian and other minoritised backgrounds in their classes and on placements by having systems in place to help these trainees to handle the racism they face on training and at placement while also handling the normal pressures of a doctorate course.'

Rennalls said the profession should avoid 'whataboutery' and take focused, targeted action while recognising that fixing this issue requires a multifaceted approach with multiple solutions. It should continue to fund and resource mentoring schemes and seek expert opinion and pay for the work exploring these issues. 'It requires knowledge, insight and expertise to understand complex and longstanding systems of oppression that cause and maintain this problem.'

Clinical psychology trainees Leanna Ong (University of East London) and Katie Knott (Lancaster University), are co-chairs of the DCP Pre-Qualification Group which works alongside the DCP Minorities Group. Ong told me she was particularly interested in ensuring that people from a wide variety of backgrounds could access training, particularly people of colour and from working class backgrounds.

'I think it's competitive enough to get onto training, so we aim to run events that are as accessible as possible, with have a range of different speakers to more non-traditional routes into clinical psychology. We've also been working with key stakeholders to influence systems around getting on to training, which can make the profession more accessible.'

The Pre-Qualification Group runs annual events to support people in their applications, as well as encouraging people who may not think their skills are the right 'fit' for the profession. They also work alongside the DCP and have represented the pre-qualified membership at meetings to discuss widening access to clinical psychology doctorates. Ong said the profession can seem inaccessible without access to good information or networking opportunities. 'We want to make that information more publicly available in different ways, so that people can find out about getting onto training, for example, through videos or podcasts.'