Why a glossary? Well, I read last week’s blog post a couple of days after I posted it and did a bit of a double take when I realised how much jargon I’d used. In a meeting at work this week one of the PWPs (see below) startled me by saying that he hadn’t ever realised that our patients might not have the same understanding of the word ‘anxiety’ as us. Well… yeah.
I started to pay attention differently to the conversations we have around the office and it’s thick with language that we’ve got a shared understanding of in the team, but that could be wildly misunderstood by anyone else. When you’re doing a specialised bit of work there’s bound to be language that’s specific to what you’re doing; jargon is inevitable and a useful shorthand. But the whole point of our job is to improve access to psychological therapies (IAPT – see below) and we all know that that’s got to start with the language that we use. I hope. So, defining some terms is probably a good place for me to start.
This is going to be a two- part blog, at a minimum. Probably 3. I’m barely halfway through and it’s at 2000 words, no one wants to read that, I’ll break it up. This week will be words we use to describe the organisational and systemic stuff, next week will be more specific terms that come out in our clinical work.
I’m too lazy to fact check myself and I do reserve the right to be wildly inaccurate when I’m writing so I’ll include some links to other sites if you want to read more about any of these things. Here goes, in alphabetical order:
CBT (Cognitive Behavioural Therapy): is based on the idea that how you think, changes in your body, things that happen around you, and how you behave can all have a big effect on your emotional state. By mapping what is happening in the here and now you can work out which techniques or changes will make the most difference to how you feel. CBT asks you to investigate yourself and experiment with changes to see what works.
Cognitive Behavioural Therapist (CBT Therapist)/High Intensity Practitioner/Step 3 IAPT worker: CBT Therapists in an IAPT service have to have a Post Graduate Diploma in CBT that is based on the IAPT curriculum, as a minimum. Some CBT therapists will have done a PG Diploma that was not specifically based on the IAPT curriculum; sometimes these CBT therapists are CB Psychotherapists who have trained to work with people who have got more complicated difficulties than the IAPT programme covers. Most IAPT services expect their CBT therapists to be accredited with a professional body. This just means that the therapists have to prove to an external organisation that their work is of a high quality, and they have to do this regularly.
Counsellors: were offering extremely high quality psychotherapy long before IAPT was imagined and, I sincerely hope, will outlast us all. Not all IAPT teams have counsellors, only the lucky ones. CBT doesn’t suit everyone. Counsellors in IAPT might have trained in a number of different modalities – psychodynamic, person centred, integrative… I honestly lose track. Whatever their training was in, they have to be accredited to work in IAPT. If how you’re feeling is very focussed on your emotions, or relationships from the past are a big part of it, then you might try counselling for depression. Counselling focuses very much on the relationship between you and the therapist; what happens between you in the room will tell your therapist a lot about what is happening for you, and they will sometimes talk to you about what they observe as a way of helping you to make sense of things and feel different.
IAPT – Improving Access to Psychological Therapies: Just over ten years ago some genius figured out that about one in four people have got ‘common mental health problems’– mild to moderate depression, stress, worry, panic etc. They looked at the research and realised that you didn’t need to wait for 18 months to have a year or two of intensive psychoanalysis to recover from these problems. 2-6 sessions of simple education and practice of some skills from CBT would be enough to help most people. They tested it out and it worked, so they proceeded to set up IAPT services across England and trained an army of PWPs and High Intensity Therapists to deliver the interventions. Its been so successful that IAPT services are getting bigger, and bigger, and bigger. Yay (for me anyway).
Low Intensity Interventions: These are the NICE recommended treatments for depression and anxiety that can be delivered by a qualified PWP. I’ll write more about these next week. I will just say that they’re based on ideas that make so much sense that sometimes you feel like an idiot for not working it out by yourself. Don’t beat yourself up, we’ve all been there and had to have the bleeding obvious pointed out to us at one time or another. But seriously, don’t underestimate the change that can come from doing something very simple very well. I’ve seen it work actual miracles.
The IAPT Minimum Dataset: IAPT was the first talking therapies project that made its therapists measure how their patients were feeling at every session. In the good old days before IAPT questionnaires were taken at the beginning and end of treatment, if they were used at all. This meant that if someone stopped coming to appointments before the planned end of treatment (which happens a lot) there was no way to know if the therapy had made any difference. From day one IAPT therapists have collected a minimum dataset at every session. This is a collection of questionnaires called the PHQ-9, the GAD-7, a phobia scale, the Work and Social Adjustment Scale and an employment question. It feels like a lot of paperwork sometimes, and I have been in appointments where the whole time was taken up with completing the questionnaires, which is frustrating for everyone. On the other hand it means that we’re accountable; all IAPT services have to report these anonymised numbers to a central database where their success or failure is tracked. A failing service will be visited by The National Team; a shadow organisation of ultra-administrators who live in the NHS basement until they are called into action. I also find the questionnaires are helpful when I’m thinking about the conversations that I’m having with someone – you’ve scored a 3/3 on poor sleep and a 0/3 on unhelpful thoughts; lets look at sleep then. Helpful.
NICE/ The National Institute for Clinical Excellence produces guidelines for NHS services. They spend their time doing huge reviews of all of the research evidence in healthcare and produce guidance on what treatment should and should not be offered in the NHS. IAPT interventions should always be NICE recommended.
PWP, Psychological Wellbeing Practitioner*, Low Intensity Therapist, Low Intensity Practitioner, IAPT worker, Step 2 worker… there are probably more that I haven’t heard yet.
This is the not-a-profession that this blog celebrates. It’s the job title for people who have done a Post Graduate Certificate in Low Intensity CBT-based interventions (IAPT) who deliver Low Intensity Interventions. If you see someone who calls themselves any of these things in an IAPT service they should have done a one year training course to become qualified to deliver the interventions. We can’t call ourselves a profession yet because we don’t have accreditation, regulation or registration. Basically there’s no way to tell if one person who calls themselves a PWP is doing the same as the next person who’s calling themselves a PWP. We keep a check on the quality of our own work with weekly supervision that uses competencies that are in our training materials, but there’s no real external checks. It’s changing very slowly, we’ll get there.
We get called, and call ourselves, a lot of different things because we’ve only been around for a decade and it’s still all settling down. My personal preference is Low Intensity Therapist, but no one is asking me. I have to keep reminding myself that this is a job title, not a personality type. PWPs (or LITs if I had my way, it sounds less like ‘poop’) tend to be intelligent, good problem solvers, a bit (“a bit”) GADy (see next weeks’ blog), ultra-organised, deeply caring and empathetic, and very sarcastic and defensive about it. Highly professional natural leaders who literally hold the IAPT programme up on their shoulders. They are the lowest paid people in most IAPT teams and in my experience only teachers are more stressed – and let’s say, lubricated (coffee or wine, everyone in IAPT seems to rely on one or both!) – than we are. GPs are catching up after the last few years. A lot of PWPs progress to High Intensity training or other training outside of IAPT within a few years, because there aren’t many other jobs in Low Intensity Interventions. That’s slowly changing too. PWPs deliver evidence based Low Intensity Interventions and provide the assessments for IAPT services. They will usually be the first person you speak to.
*What’s in a name indeed. Whenever I hear my full job title I imagine someone in London, or certainly down south, spitballing ideas onto a flipchart in a meeting to try and impress someone, and everyone in the room being fed up and/or hungover and/or ready for lunch and going – ‘yep that’s good enough, lets eat’. I, and most of my colleagues, can’t stand this job title/name for our emerging profession. It’s twelve syllables for crying out loud. Twelve! How is a patient supposed to make sense of that or remember it? Most of the people in my area have a reading age of 7, they can’t even read my job title. How do you abbreviate it? PWP sounds like ‘poop’ if you try to say it as a word. It’s meaningless and confusing. Sorry not sorry for the rant.
The Stepped Care model and Step/Tier/Level 1, 2, 3 and 4 it might not work exactly like this in practice…
The stepped care model is a way of arranging services so that people get the “least burdensome” treatment that has a chance of working, as quickly as possible. Least burdensome means taking the least time, effort and money. Some people might progress up the steps one after another until they feel well. Other people might jump from steps 1 or 2 to 3 or 4 because you should only be offered something that has got a good shot at making a difference.
Step 1 is identification and information giving – for example if your GP or a nurse notice that you’ve got symptoms of depression or anxiety they should give you some information about it, like the SHARP material, or a good self help workbook, and check in with you in a few weeks to see how it’s going. If they think you’ve got depression or anxiety after that waiting period they might advise you to book yourself onto an IAPT intervention, or have an assessment appointment with a PWP.
A psycho-education course or computer programme about something like depression, panic, stress or worry, or PWP assessment takes you to Step2 where you’re getting time with someone who is trained to identify depression and different types of anxiety, and offer evidence based Step 2 (otherwise known as Low Intensity) treatments that, according to NICE, have got at least a 50% chance of making you better. This blog is about Step 2, lots and lost of people get better at this step and don’t need anything else.
Step 3 is for people who have given a Step 2 intervention a good try, but it hasn’t been enough to manage the depression or anxiety. Sometimes people meet a PWP for one or two appointments and it turns out that the anxiety is OCD, Social Phobia, Post Traumatic Stress Disorder or a specific phobia. When anxiety is that specific there is no evidence that Step 2 treatments make much difference and you should be offered and assessment with a CBT therapist.
Step 3 is also home to counselling which is used to treat depression, not anxiety. In some areas there are specialist counselling services outside of IAPT for things like rape and sexual abuse, domestic violence, bereavement and so on, that might be more helpful than generic counselling for depression. It varies depending on where you are.
Step 4 is usually outside IAPT except for a few small teams of clinical psychologists who work in some IAPT services. There are a lot of reasons why IAPT might not be helpful for someone, it was never designed to replace a mental health or social care team. If your problems are caused by something like an eating disorder, domestic abuse, substance use, psychotic symptoms, ADHD or bi-polar disorder; then what IAPT can offer might not be a good fit, and might make you feel worse, not better. If you aren’t sure about IAPT then have a chat with your GP to talk about what you are looking for and the options they can refer you to. Some Step 4 services are based in hospitals and some are in community health centres. IAPT workers might ask your GP to make a referral to step 4, and you would usually no longer be an IAPT patient if you see a more specialist team.
As I type this I can see how complicated it must look from the outside; from the inside it makes a lot of sense. Hopefully next time you sit in front of a nice young thing who introduces themselves as a ‘Psychological Wellbeing Practitioner in the Improving Access to Psychological Therapies Service’ and shoves a load of questionnaires at you, you’ll feel a little less stunned and a little more in control. It’s good practice for us to give our name, job title and the name of our team to someone at the start of an assessment; maybe we just need to pause afterwards and ask if everyone understands what the words mean?
Tune in next week for the clinical glossary, after that I promise I’ll start writing about the good stuff. Let me know if there’s anything that you want in the glossary in the comments!