Improving Access to Psychological Therapies (IAPT for short) and the work of Psychological Wellbeing Practitioners (PWPs) involves a lot of jargon. It seemed like a good idea to explain some of these words and terms before I get on with writing the other blogs I’ve got in mind. If you don’t know what a PWP is then the rest of this site isn’t going to make much sense! In the IAPT Glossary Part 1 I did my best to explain IAPT, the jobs in IAPT, and the systems that we use and work within, in less than 3000 words. That was a mission and I think I failed it, but hey, I’ll keep writing and it’ll all make sense eventually. This time I’m looking at the words that describe what we do. Before I start I’ll just mention that the Exeter and Northumberland self help guides are high quality resources that are worth reading if you want to know more about the Low Intensity Interventions I mention below.
I’m not going to do this one in alphabetical order, just feeling like a maverick today.
There’s a big disclaimer here that IAPT teams all do things differently. Where you live will make a huge difference in how your local IAPT team is organised and the specific duties that PWPs are given. If you live in a region where there is no IAPT you might still be able to find Low Intensity Practitioners in various guises who work on the same ideas. I’m writing about my service and the half dozen or so other services that I’ve had contact with, but things might be different near you. What should be the same everywhere is what PWPs offer – all PWPs should have the same qualification and be offering the same information and interventions. It’s worth noting that I recently did a web search for Low Intensity Interventions and found that a lot of these terms are used interchangeably and flat-out differently by different commentators. The list below reflects my understanding but there isn’t a universally agreed definition for some of these.
The “disorders” (what PWPs are trained to assess and treat)
Anxiety: One of the two “disorders” that IAPT services are designed to treat (the medicalised language we use in IAPT is a topic for another time). Anxiety is a blanket word for a number of different problems that have all got their own diagnostic criteria and recommended treatments (Generalised anxiety disorder, phobias, panic attacks, OCD, Post Traumatic Stress Disorder, Health anxiety, Social Phobia, stress are all types of anxiety). Anxiety disorders are characterised by physical changes – the Fight/Flight/Freeze/Flop system is active – and something is feared. This leads to a cycle where the physical system prompts changes in thinking, emotion and behaviour that can become self-maintaining and very distressing and restrictive. And when I say distressing I really really mean that. Everyone in a human body has felt anxious, but for some of us it can cycle into a real problem. Fear is a bully, and if you let it tell you what to do your life will get very small.
Depression: One of the two“disorders” that IAPT services are designed to treat (yes, there are some things that I will always bracket with ironic quote marks). Depression is sometimes caused by life events; for example, you lose someone or something that really mattered to you, naturally you feel sad about it, but some people get stuck in the sadness and it becomes an illness that has taken on a life of its own. Sometimes people experience depression for no apparent reason. By the time someone is talking to me about it I’m not too worried about where it came from, I’m thinking more about what we can do about it. Depression is characterised by feelings of sadness, hopelessness, guilt and self blame, physical tiredness, disrupted sleep, changes in appetite and lack of interest and motivation to do things. The joy goes out of life and you can feel like you’re carrying a heavy weight everywhere that you go. Doing even basic actions can take huge effort. Just like anxiety, depression can pull your thoughts into different shapes; it distorts how you interpret the things that happen around you, how you remember the past and how you imagine the future.
Low Intensity Interventions (what we do)
Assessment: Anyone who has ever accessed therapy of any kind, or used a health service, is probably familiar with the idea of an assessment appointment, this is usually the first appointment. Think of it as a first date, do you feel a spark? If not then you might decide not to progress past coffee, or carry on with more appointments if we stop using that analogy. Equally the PWP will be trying to work out if you and the service are a good fit (and just for the record – if a PWP ever tries to date you please tell their manager, they shouldn’t do that).
You can have some time with IAPT and never have an assessment appointment; many services are opening up their psycho-education courses and computerised CBT programmes for self-referral, where you can book on without any kind of screening. But if you want to talk to a person one to one, or if you aren’t sure about the best option, then an assessment appointment is where you start.
In an assessment appointment the PWP will be trying to work out the 4Ws (What the problem is, where, who with, and when it’s most likely to happen) and a 5 areas (the context of the problem, how it affects your thoughts, emotions, body and behaviour), then round it off with a goal for treatment and a plan for what happens next. This information is supposed to be gathered using a system of open to closed questions called “funnelling”, and the PWP should have an attitude of non-judgemental listening, accurate reflections should be offered, the PWP should be offering empathy and providing enough accurate information to normalise the problem at the same time. Oh, and the PWP should get a completed a minimum dataset (see the IAPT Glossary Part 1) and check substance and medication use and as well. All of this is supposed to cumulate in a problem statement that the patient produces with prompting from the PWP which gathers all of this information together in a short paragraph. Then based on that the patient is expected to come up with a goal for treatment – specifically what is supposed to be different when the work with IAPT finishes.
If that sounds like a lot, well, it is. I actually gave myself a headache from the effort to not roll my eyes while I wrote about problem statements. Get real. Back in the olden days when I trained we were supposed to do assessments in 30 minutes. In these more enlightened times some places give PWPs 45 minutes, which takes us a step closer to the therapeutic hour.
The purpose of an assessment is to pin down what problem someone wants the IAPT service to help with so that the PWP can offer the local menu of evidence based treatments for that problem.
I’ve always wondered what an IAPT assessment feels like from the other side…
Behavioural Activation: is the go-to treatment for depression. There can be a lot going on when someone is depressed, but what they are doing with their time is the easiest thing to start changing. A PWP typically has somewhere between 4 and 6 30 minute appointments with someone, so we want quick results. If someone is well enough to understand that how they use their time can make a huge difference to how they feel, and willing to try to do things differently, then BA is worth a go. The core principle is that instead of waiting to feel motivated and interested in doing things, you do things anyway. By scheduling in different types of activities (and doing them) you start to create opportunities to feel different.
Cognitive Restructuring: addresses thoughts that have been pulled out of shape by anxiety or depression. There are certain types of thinking that are more likely to occur when you’re depressed or anxious, and thinking those types of thoughts keeps the problems going. Being able to spot those thoughts and inject some balance can be very powerful. This technique helped me enormously 15 years ago when I was crippled by social anxiety, but it can be a tricky one to deliver as a practitioner. CR is concerned with the content of thoughts and requires an ability to articulate what is going through your mind. That’s really difficult for some people to do. My favourite resources for CR are the Chris Williams booklets (I’m showing my age again).
Graded Exposure Therapy: Is how we push back when anxiety is making the world shrink in on someone. GET might be part of a panic management intervention but can be used to overcome other types of anxiety. GET means writing a list of situations that you don’t go into (that you avoid) because the anxiety makes you too uncomfortable when you’re there. You rank these in order of how anxious they make you. Then you pick something ‘difficult but do-able’ (usually at about 30% anxiety) and deliberately put yourself into the situation you’ve been avoiding and stay there until your anxiety subsides. Then you repeat that 3-4 times a week until that situation doesn’t make you anxious anymore. GET is hard work but very effective. I’ve used it on myself and gosh golly that was a stressful couple of months, but I can drive on the motorway now and not have a panic attack. Yay! This intervention should not be used in Low Intensity work to treat Social Phobia or OCD, those specific types of anxiety need a different protocol that should be delivered by CBT therapists at Step 3. I’m not kidding about this.
Panic management: Panic is truly horrible; anxiety so uncomfortable that you really believe that it’s going to kill you? No thanks. But knowledge is power and your PWP is your learned guide (I snort-laughed when I wrote that. We do our best.), you can do it. I’m not even sure that panic management is still on the training curriculum under this name, I should find out, but it involves providing education about anxiety, panic attacks and panic disorder and then supporting someone to use GET to do the things that they have been avoiding because they were frightened that it might set off a panic attack.
Problem solving: What it says on the tin really. Both depression and anxiety can make normal life feel overwhelming and difficult. Both depression and anxiety can make it harder to figure out solutions and plan helpful actions. Problem solving is a seven step guide to working your way through a problem.
Sleep hygiene: does not mean having a shower before you get in bed. Sleep hygiene is information and support to tidy up your behaviours in the day so that you give yourself the best chance to have a good night’s sleep. For real problem insomnia this is probably going to be followed by sleep retraining. Not all PWPs are trained in sleep retraining but there are good resources online where you can find out more.
Worry management: Ah worry, my old friend… Yeah, most of the 4 thousand or so people who I’ve worked with over the last 11 years have been at least a bit bothered by worry. Worry is something we could all do with a bit of education about. It’s a natural helpful function of your mind – the ability to think forwards and scan the future for things that you need to plan for – that gets distorted and over-grown.
Someone who has a problem with worry can’t relax, they can’t enjoy the things that are happening right in front of them, they often don’t sleep well and this can bring their mood down. Their appetite for and enjoyment of food might be affected. The things that they are imagining in their mind feel more real and threatening and important that the things that are actually going on in front of them. Worry tend to be underneath all of the other types of anxiety, it keeps your background level of anxiety a little bit higher than it needs to be; so when other types of anxiety happen they start off worse then they need to be.
Cognitive Restructuring focuses on the content of your thoughts – what are the exact words that you’re saying to yourself? Worry management focusses on how you’re thinking, not what, and aims to reduce the amount of time in the day that you spend worrying. You could be worrying about the weather tomorrow, a deadline, whether or not you’ll be able to have children, if your car will pass it’s MOT, if the test results will mean that you’ve got cancer… and it doesn’t matter. Worry management is about how you’re thinking, not what you’re thinking about. People have got really cross with me about that over the years; ‘I’m telling you that I think I might never be able to have a baby and you don’t care!’. I do, I do care very much. But my sympathy wont relieve the distress and impact of worry. A practical approach to putting these thoughts back in their box might… Well, it’s not for everyone.
Worry is also known as Generalised Anxiety Disorder which gives us the very convenient ‘GAD’. Last week I described PWPs as GADy – this is a shorthand way of describing someone who does a lot of worry behaviours – agitated movements, fast pace of speech, constant predicting bad outcomes, difficult to talk rationally to. We always put our GADishness back in a box when we’re talking to our patients but it comes out to play in the office, and we make fun of each other for it constantly.
How we do it
So they’re the Low Intensity Interventions that PWPs can deliver. None of it is rocket science but most of it is stuff that people don’t intuit. There are lots of ways that you can get your hands on this information, and lots of ways that PWPs deliver it.
Self help: is where you think – ‘not a guru made a good point there, I’d like to find out more about BA’ and you go away and look up a good book and have a go at using the ideas on your own. Brilliant. Sometimes when you’re reading your book and not getting the results that you want some guided self help can be a good idea.
Guided self help: is where you use the same book or information as self help, but you have support from someone who knows what they’re talking about (most PWPs fit this bill) to help you to really understand the material and to encourage and support you to put the ideas into practice. Most PWPs have some time in their week when they offer one to one appointments either in person or by phone to do this kind of work.
cCBT: is computerised CBT where you get the ideas from a validated computer programme that might also offer individual support or contact from a PWP or other qualified helper. I’ve seen people get really good results from some of these programmes and they obviously fit in better with a busy life than having to go to appointments. Some places will want you to have an assessment appointment before they give you access to the programme. IAPT services have got a duty to provide treatment that’s got a chance of working, so they will probably need to talk to you to make sure that’s the case.
Psycho-education courses: are not group therapy! I wish IAPT services and PWPs would banish the word ‘group’ from their vocabulary. PWP training does not cover running a group where people are processing big emotions and experiences in the room. What we do tend to be really good at is running well presented courses that cover the basics of Low Intensity Interventions in an accessible way that doesn’t put anyone on the spot. These courses are sometimes delivered lecture-style like the brilliant Stress Control course that Jim White started in Glasgow, sometimes they are smaller and delivered as a workshop. Psycho-education courses are marvellous but people don’t go on them because they imagine sitting in a circle and talking about their problems and feelings in a room full of strangers. That can be really helpful for some people, in some circumstances, to help with some problems. But at Step 2 in IAPT? No, just, no.
That’s Probably enough for today
OK, with the two IAPT glossary posts I feel like I’ve given you enough background information to make anything else I write about IAPT and PWP work make some sense. I’ve got a list of eight topics ready to write over the next few weeks and more ideas will come. If there’s anything you want to know more about, or that you think I’m missing, then please let me know in the comments on here or on twitter @notapwpguru. If you want to write a guest blog I would be very excited to hear from you.
Thanks for reading!