High Volume, Low Intensity, and Chaos

In this week’s blog I want to talk about the phrase I’ve heard more than any other to describe low intensity work in IAPT: high volume, low intensity. It’s our mantra. As always, don’t take this 100% seriously and do refer back to the IAPT Glossary if you don’t understand any of the words or phrases I use. I’ve linked to a couple of articles that are much more worth reading than this blog – check them out!

I need to give a disclaimer because this blog might be a bit ranty: Just remember that I love this job, I love the work that PWPs do, I’m inspired and amazed by my colleagues (including our managers) every day. The things that my patients have shared with me and the courage that they’ve demonstrated humbles me. I think IAPT is a visionary project that has done a tremendous amount of good. That being said, it feels like the system we work in is a relentless machine…

The deal with Step 2 work in IAPT is this: PWPs were designed to see a lot of people. That’s how they (I’ve got no idea who “they” were, but God bless them for giving my life purpose) got the money to set the whole thing up in the first place. Lord Layard wrote a report saying that lots of people were depressed and anxious, and people being depressed and anxious was costing the economy £X Billion every year. ‘We need a cheap way to get them better quickly and keep them working’ he cried, and the PWP was born (If you read the report that I’ve linked to, it’s actually very compassionate and places an emphasis on relieving human misery, but I’m pretty sure it’s the economic argument that prompted the funding for IAPT).

Someone figured out that you don’t need a clinical doctorate or five years of psychotherapy training to identify common mental health disorders and talk someone through what they needed to do to get better. If you had a workforce who trained for one year instead of three to five, obviously you wouldn’t have to pay them as much. They could be supervised by better qualified and more experienced people (you’d have less of those because they cost more) and it would be fine. Because this army of new and cheaper workers would only see people with mild to moderate symptoms their work would be easy, so they could do more of it, they could see lots of easy to treat people.

On paper that sounds fair enough. Genius, actually.  

It does work well a lot of the time, however there are multiple problems with this system and this article in The Psychologist from 2009 did a brilliant job of predicting most of them. First, it ignores the fact that the theory in practice often boils down to sitting two people in a room together. People. People are never predictable. And you’ve told one of those people to care about the other and feel responsible for them, and trained them to genuinely empathise with difficulty and trained them elicit information. Brilliant. So, for example, the bloke who keeps going to his GP with persistent headaches and insomnia and got fobbed off to an IAPT appointment because the GP was at their wits end suddenly, after a nice young woman sits and asks him some open questions, has PTSD. That happens a lot.

‘We need a cheap way to get them better quickly and keep them working’ he cried, and the PWP was born

Over the last few years there are a growing number of people in the UK who’s lives are less predictable than they used to be. A psychological therapies service can support someone to make internal changes – to learn a way to understand their experience, manage how they think about things, make informed choices about what they do and process strong emotion. What we can’t do is control or affect the circumstances of someone’s life, and people are increasingly in circumstances that are genuinely overwhelming, that they are powerless to control; even if they weren’t already crippled by depression and anxiety. We rely on other organisations to help with that: social activities, finances, physical healthcare, immigration, housing, carers and caring needs, cooking lessons, support with exercise, how safe someone feels when they leave their house. All of those things are more difficult to manage than they used to be, and provision is changing fast.

Second, this system replaced existing counselling and therapy services with the shiny new workforce. In some regions IAPT has got bigger while not just counselling but mental health services have got smaller. It’s not unreasonable for people who use and refer to services to think that a replacement will be at least as good as what was there before. Add to that the fact that most GPs and other healthcare professionals don’t see much difference between a multidisciplinary mental health team and a psychological therapies service. (OK that’s probably unfair but that’s how it feels on most days). And they definitely don’t understand the difference between a counsellor with six years of training and twenty years of experience and a PWP who graduated with a 2:1 in psychology two years ago, did a support worker job for a year, and is now seeing their patients for IAPT assessments at the start of their PWP training. If I had a quid for every time someone has called me a counsellor I’d be able to buy a tropical Island and retire.  

Throw that together with stepped care; you make entry into services go through one point, often without any kind of screening for suitability, so that the first person any new patient to the team meets is the most junior, least qualified person who has about half as much time to think as anyone else. You also make sure that services who operate any kind of screening system are penalised, thanks to the IAPT targets.

What’s it like to be a PWP in that system? Let’s try a sample session. NB: this is completely fictional but the elements are typical enough to use as an example.

PWP and Patient (PT) are sitting in a clinical room in a community healthcare clinic. The floor is laminate, the walls are white, there’s an examination couch and curtain in the corner of the small room, cupboards and draws full of medical equipment, bars across the window, a vague, funny smell in the air. They’re sat kati-cornered at the desk with the PWP in the desk chair and Pt on a plastic chair pulled up to the corner. It’s the third time they’ve met so they’re getting used to each other. PWP is a young white woman dressed in smart-casual, Pt is a 21 year old man in T-shirt and jeans, there are holes in his trainers and a faint smell of BO. In previous appointments Pt has scored high on the depression questionnaire and is describing having trouble motivating himself to look for work. He’s constantly restless during the session.

PWP: Hiya, thanks for coming today, how’s everything going this week?

Pt: So much has happened this week, just, so much. I need to tell you about my mum…

PWP (sympathetically): It sounds like you’ve had a lot going on. So before we get started shall we…

Pt: You know I told you about mum?   

PWP: I remember you mentioned her last week and I know things have been difficult. Shall we just quickly have a look at…

Pt: Difficult is a major understatement. You know she left five years ago and I’ve been with dad, that bastard, well she’s come back and dad’s got really upset.

PWP (genuinely sympathetic): Wow, it really has been a lot this week. Did you manage to do your questionnaires at all?

Pt: Oh yeah, but I forgot them on the kitchen table.

PWP: Oh that’s a shame, so we’ll need to take a few minutes to fill those in today. While you do them maybe I could look at your diary?

Pt: I didn’t do the diary, I couldn’t remember how to fill it in.

PWP: OK, well we’ve got thirty minutes maximum today so shall we have a think about what we want to cover? I know you’ve had a lot going on at home and that’s been even bigger this week; we were looking at how you could set up some routines to help your mood to improve. We were going to look at how that’s going, check your diary and see what had worked and if there was anything I can do to help with planning next week. I can see you’re really unsettled by your mum coming back but you might remember what I said about what I can help with? If we start talking about how you feel about your mum we might end up opening things up that I can’t help you with.

Pt: Yeah, mum coming back is a big deal.

PWP: So we need to think about what we’re going to do. Do you remember when I showed you the ABC?

Pt: No

PWP: that was that diagram we filled in that showed how your body, behaviour and thinking can all affect each other

Pt Oh yeah…

PWP: and I explained that the work that I do is based on that. We did say that if you need to talk about things in the family and the big emotions that go with that, then you’d maybe need to see a counsellor instead of me.

Pt: I thought you were my counsellor? Anyway, I can’t get my diary back. Dad got so cross this week, he got drunk last night and came up to my room yelling at me. We got into it and had a fight and he kicked me out. I might go to the police.

PWP: You got into it with your dad? What kind of fighting do you mean?

Pt: He punched the back of my head so we got into it. Honestly, do you think I should go to the police?

PWP (putting her pen down): So have you got somewhere safe to stay at the moment?

Pt: I’m with my girlfriend, her mum and dad don’t mind if I stop over for a bit. I can’t go back to dad, he’s a right bastard.

PWP: Do you feel like you need any help with sorting it all out?

Pt: Yeah, maybe

PWP: OK, let me get you some numbers for SHELTER. If you decide to talk to the police do you know how to do that? It’s important that you feel safe.

Confession time: if I was the PWP in the scene above I’d probably have put Pt on a waiting list for counselling to talk about his relationship and family dynamics and how they were contributing to his poor self-esteem and depression. Then, knowing that the waiting list was 6-9 months, I’d have helped him to access all of the practical support I could think of before I ended our appointments. That’s not, technically, the right thing to do, but I’m not a guru and sometimes I get things wrong.

The protocols for low intensity interventions take 4-6 weeks to go through. The person who’s learning about them and applying them needs to be in stable circumstances; This lets them commit to attending regular sessions, feel safe and calm enough to learn while they’re in the room or looking at the material, and have time and energy to practice the ideas when they’re at home. Someone who’s behaviour and circumstances are not stable and predictable is sometimes called ‘chaotic’. People in chaotic circumstances, like PT, are going to struggle to get the most out of low intensity work. Sometimes we have to just say this isn’t the right time, signpost people to the services who can help with whatever is happening and say ‘come back when things have settled down’. Which makes us worry that we’re giving up on someone (even though we know that we have done everything we can, and usually a bit more), and the patient might feel like therapy is useless because just when they needed someone to talk to the most, they were told that they couldn’t have more appointments.

Think about meeting 8-10 people a day with similar circumstances and distress …think about caring what happens to all of them, think about having to assess and manage their risk… while being trapped between a rigid system on your side and a disintegrating system on the outside. Then think about if the phrase Low Intensity fits.

So what’s this got to do with our high volume, low intensity mantra? You remember the deal – you see lots of people to do easy, straightforward work and that’s OK because each piece of work doesn’t take too much out of you. Now think about PT being the thin end of the complexity wedge. Think about meeting 8-10 people a day with similar circumstances and distress (which can happen in some areas), think about caring what happens to all of them, think about having to assess and manage their risk of harm to themselves and others, and the risk of harm from others, and think of everything that could help them while being trapped between a rigid system on your side and a disintegrating system on the outside. Then think about if the phrase Low Intensity fits. The addition to the IAPT handbook that was published this year did specify that PWPs in full time employment should do 20 hours of clinical work a week, this is better for us than demanding a set number of sessions. This gives local teams some flexibility to allow more time for some appointments, and PWPs the flexibility to manage their week.

Amongst all of that some really good things happen. Thousands of people go to IAPT services every month reporting symptoms of depression and anxiety; more than half of them leave services without those symptoms bothering them. If the first and sometimes only person you meet on that journey is occasionally overwhelmed and a bit cross, well, they’re human too. I’m grateful for the opportunities to sit in those clinic rooms and meet the people who come to us. I’m grateful for interesting work that makes a difference, and I’m hopeful that the systems around us will adapt and mature if we give them a bit more time.   

Thanks for reading and as always, please let me know what you think on twitter @notapwpguru or in the comments.

5 thoughts on “High Volume, Low Intensity, and Chaos

  1. I’ve been an IAPT patient who was really too ill for IAPT like so many others. I also work with services as a service user consultant so I know a bit more than the average patient about what your work is like. This is a superb blogpost and I think you’re all heroes.

    Liked by 1 person

  2. “Over the last few years there are a growing number of people in the UK who’s lives are less predictable than they used to be” *checks date of publication* Oh my sweet summer child.


    1. Haha, yep, even the austerity years didn’t prep us for the pandemic. I’d say ‘if only I’d known’, but I’m rather grateful for that sweet innocence!


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