For the Alliance!

I’m a huge geek so I’ll happily admit that the blog title this week is an homage to the recent re-launch of the classic version of World of Warcraft. I stopped playing that game when I started my PWP training and had to get a life. My preferred faction in the game was The Alliance, which happened to be on my list of topics to write about. You can’t ignore that kind of synergy (did you ever play bullshit bingo at work? One of our old managers introduced me to it – synergy is an easy one to tick off).

A good PWP does something very simple exceptionally well

PWP assessment

Last week I talked about how our high volume of interactions with people who come (or are sent) to IAPT can demand a lot from us. This week I want to talk about how those contacts with people can be life-giving. I’m taking a very rambling look at the alliance between the PWP and our patients, how this is formed, what it means for us as practitioners and a profession; with a lay-by into the PWP assessment where it all starts. A lot of this will be very basic if you’ve got any experience as a therapist. Please remember that I did my training a decade ago and have only opened a Reach Out manual again to write this post! I’m starting from a belief that there is nothing more important or helpful than genuine connection and compassion between people; at the same time I acknowledge that the work we do has its own requirements that we have to respect if people are going to experience change.

In the IAPT Glossary Part 2 I wrote about the PWP assessment; How we have to collect a vast amount of information in a short time. WordPress tells me that over 200 people have visited this site (which is blowing my tiny mind!), and about 7 of those people have looked at the Glossary so here’s what I wrote about assessment:

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:

Be genuine

Have an attitude on non-judgemental listening

Accurate reflections and summaries should be offered

The PWP should be offering empathy (preferably genuine but not necessarily, see below)

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 Part1)

and check substance use (alcohol, tobacco, prescribed and “non prescribed” medication, caffeine) as well

Assess the impact of any Long Term Health Conditions (LTCs) and if these are being managed adequately

If that sounds like a lot, well, it is. 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…

https://notaguru.blog/2019/08/20/the-iapt-glossary-part-2-what-does-a-pwp-actually-do/

On paper this system of information gathering can sound a bit dry. The theraputic alliance is touched on in most PWP training courses but PWPs aren’t supported to understand and manage this crucial aspect of our work with any sophistication, you have to work it out as you go along. It gets worse; in the Reach Out training manual that we used back in 2010, alongside a list of the items of information we have to gather, there appeared ‘empathy dots’ to remind the trainee PWP to make ‘empathy statements’ at appropriate intervals. ‘It sounds like that’s been really hard for you.’ Is an example of an empathy statement. Sometimes IAPT deserves its bad press. Our recent trainees hadn’t heard of empathy dots, thank smeg. What was a bit worrying was that they hadn’t heard of common and specific factor skills either.

Empathy dots in the Reach Out training manual 2nd edition

So far, so dreadfully like a horrible parody of CBT. However, sometimes it feels like that training give me a magic formula for the ultimate healing potion.

PWP as a profession

Being a PWP is not recognised as a core profession. It can’t be, the role hasn’t finished growing and defining itself. Which PWP hasn’t been asked to try a bit of this and that by a CBT therapist or Clinical Psychologist (‘What do you mean you haven’t been trained in grounding? You can read up on that easily, just have a go…’)? Who hasn’t occasionally drifted into a supportive listening session where only common factor skills and no specific competencies are offered to the patient? Despite that I would argue that there will be a case to make one day that this is a core profession, distinct from other professions, that will be registered, regulated and accredited like other professions. I want it to become weird for someone to become a PWP in order to be a clinical psychologist or CBT therapist, just as it would be to become a physiotherapist in order to be a nurse or occupational therapist. We’re a long way away from that at the moment; looking at what the role is, what it can accomplish, and what PWPs can get out of doing it, will help along the way. Better career progression wouldn’t hurt either.

Low Intensity work delivered by PWPs is not counselling, and it is not CBT. It’s one of three distinct modalities that all offer something valuable and different. It is Low Intensity work. It has its own boundaries and definition. There are things that we do very well that are not covered by the competencies and experience of the other professions, and there are things that are not within our competencies. It has its own subtleties, which is where the life-giving bit comes in.

I want it to become weird for someone to become a PWP in order to be a clinical psychologist or CBT therapist just as it would be to become a physiotherapist in order to be a nurse or occupational therapist

The job of PWP was originally imagined as an aspirational post for people who were in support worker roles, ex service-users and volunteers who wanted to progress to paid work in the NHS. In the early literature you get the sense that the PWP role was supposed to reach the limits of the capabilities of the people who were doing it. For the most part that isn’t happening. We’ve got services full of ambitious, highly intelligent, passionate young people who are more than capable of becoming competent in any clinical or leadership role that they decide to take up. A lot of them leave in order to explore their capabilities further (and to achieve greater financial security, further education and higher status). Being a PWP is a tough gig – I’ve got a lot more to say about that on other days – it’s hard work with little reward. Despite that we have managed to attract and retain a core of people who decide to keep doing it.

One of the things that sustains people in this job for years is the repeated opportunity to meet people, form an effective connection, and facilitate change. A good PWP does something very simple exceptionally well. To do that you have to stretch your creativity; how do you make low intensity interventions accessible to everyone who walks through the unguarded door? There is a constant balance to find, different for every patient, between common and specific factor skills. You have to work out what will help someone, maintain fidelity to Low Intensity work, and provide enough genuine interpersonal competency to engage someone. This keeps things very interesting. The balance is different in every appointment. There are a lot of opportunities to get things right and the results are often immediate and rewarding. Here is an example of how we might negotiate an assessment and start to form the alliance with someone:

You start with an open question ‘How are things’ ‘Can you tell me what’s brought you here?’ ‘what are you wanting some help with?’ (not all of them! Pick one.) The person starts to describe what’s happening in their lives and you start to catch things from them – an emotion here, a worry there, a verbal or non-verbal flag that shows you where the most powerful part of the difficulty is.

Then you start to summarise and reflect that back to them:

‘You’re telling me that the pain has had a big effect, when you said that it stops you from playing with your grandchildren as much as you want to, that felt like a real loss…’

‘Let me just check I’ve understood right, you said…’

The more you demonstrate that you’re listening and understanding the more you see the fears, hesitations, blocks to engagement, external worries, all fall down like bowling pins.

You narrow down your questioning to get to the specifics ‘How many hours do you sleep most nights? Exactly what words are in those negative thoughts? How many times do you leave the house most weeks? Stopping to summarise and reflect frequently.

Then when you’ve got a picture, you describe it to them and start to demonstrate how one thing affects another: This is the situation; what you’ve told me about the past and what’s happening in your life now that feels important. In light of all of that, when you’re sat at home alone in the evening this starts to go through your head. Those thoughts don’t stop and because of them it’s been hard for you to get to sleep for a few weeks; you’re tense in the day because you’re worried about getting to sleep at night. You’ve started staying in bed later in the day and stopped talking to your friends because your mood is low. Avoiding your friends is making you feel lonely and guilty, you’ve started blaming yourself for things going wrong. You’re saying that what you really want is to feel happy again, and you aren’t sure what that would look like or how to make that happen.

People are often startled when they hear their picture described in this way. What’s been happening starts to make sense differently, and the atmosphere between us usually shifts. Sometimes there are tears as emotions are accessed and acknowledged, although I’ve never looked for tears as a sign that I’ve done something right (I know some people who do). What this method does is prove that I’m not just hearing, but listening and understanding. After that it’s easy to start one of the interventions because the other person trusts you, and you’re both confident that there’s a shared understanding of the problem.

The addicted magician

Of course you realise when you’ve got the balance right and someone has experienced change and relief during your conversation with them; those moments of mastery and connection can be a bit addictive. It’s one of the things that keeps us going, the reward of seeing that immediate effect. I’ve wondered if that’s why there is sometimes resistance to promoting other delivery methods for Low Intensity interventions. How can we suggest that a cCBT package, a Stress Pack lecture course or an educational class could be as good as what I can offer? I’m the magical therapist! Well, no. Actually the data tells us that those more impersonal ways to access the low intensity information and interventions are at least as effective as one to one work, often more so. If it feels like I’m contradicting myself, think of it as another balancing act in PWP work: how much alliance is enough, how much is too much?

In the end, any relationship we form with someone is there to function as a conduit to information that will empower a patient to be their own therapist. The smaller the part we as individuals play in that process, the better. We’re the start of a journey, a quest giver; we aren’t the magician or warrior who wades in and kills the monster.

If you’ve made it this far, thank you for reading. As always I’d love to hear what you think about this site, especially if you’d like to write a guest post. Find me on Twitter @notapwpguru and have a great week.      

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