When I set up the notaguru website and started writing this blog I wanted to answer the questions ‘What does a PWP do?’ (because I’ve never read anything that actually sounds like what I do from day to day) and ‘what has being a PWP done to me?’ (picture of the silent scream) and ‘how the hell have I managed to do this for so long?’ (short answer: wine and sick leave. And finding the things that I can celebrate in the role.). I used the last blog to get on my soapbox because the site attracted a wave of interest and I couldn’t resist the opportunity to say something to that audience. From now on though, it’s going to be a bit more personal.
This blog comes with a trigger warning: I do mention some distressing things that have happened during my working life and that people have told me; this touches on violence, sexual assault and self-harm, please take good care of yourself while you read. I also swear in this one.
I’ve had a massive back and forth about what I should include in these blogs. Inevitably the bits of the work that have had the most profound effect on me are the stories and experiences of the people who I have met in my clinical work. How much of their story is my story? Can I talk about what they’ve told me in a respectful way while maintaining confidentiality and good ethical practice? I don’t know. What I do know is that who I am as a person has changed because I have worked as a PWP in IAPT, and the things that people have said to me are what has driven that change. For this blog to do what I need it to do I’m going to have to describe some of my experiences. I will anonymise and fictionalise to the nth degree. Anything you read here will not be a faithful account of what happened in real life, I’ll change things around like a game of find the lady; I’m going to hit the bits of the experience that I need and not include the rest. I hope that’s comfortable for everyone.
In this blog I want to write about one of the most difficult bits of being a PWP (remembering that the experience of PWPs in different IAPT teams is wildly different, this is just my experience). This is about how doing this work makes it impossible to hide away from the most difficult experiences that people have had, the powerlessness of not being able to predict or control who and what will walk into your room every day. The vulnerability of being alone.
In order to meet the access and waiting time targets a lot of services are doing more appointments by phone, and offering more psychoeducation courses at Step 2 than we used to. In my local team we still have substantial amounts of time spent in ‘clinic’; that is where we use pretty much any room that someone will give us and we see patients face to face for one to one appointments. The majority of my clinic work has been conducted in this way, and in one of the most socio-economically deprived areas in a big northern city. I live and work in the same city, which does make it difficult to draw a line under the work day. I’m middle aged, middle class by background, and white. My parents are both professionals and we always lived in places where it felt safe to leave the house and play. When I was growing up my experience of the world was safe, and I’ve become more grateful for that privilege every day for the last ten years. It didn’t particularly prepare me for IAPT though.
About 8 years ago I was in a clinic at a GP surgery less than 3 miles from my house, in a neighbourhood that had a bad reputation and extremely low property prices. My clinic day was split evenly between assessments for new patients and treatment appointments to support people to use a Low Intensity intervention. One of my new assessments scored full marks on the depression and anxiety scales, indicating they were severely affected by both. I had checked all of the notes available to me before the appointment. They had no history of mental health treatment in the city and the GP had simply put ‘Tearful, see IAPT’ at the end of a physical health consultation. I asked the usual question; ‘Can you tell me if anything happened that might have made you feel this way?’ Amongst a history of family breakdown and domestic difficulty they described that a couple of months before they had been at home with their partner and three children. The family were in the front room when a car drove past their house and the passenger in the car opened fire on the house with a gun. My patient described trying to keep their children safe while the windows broke and a drive-by happened in an English neighbourhood not 3 miles from my own home. They found out later, through neighbourhood gossip, the shooters had not been caught by the police, that the shooters had meant to target a different house on the road.
It took me about a year to realise how much that story affected me. Until then I didn’t think people had guns in England. Naivety doesn’t last.
Sometimes I describe the things that have been difficult – and there have been some very bleak times in my PWP life – and wonder if I’m feeling sorry for myself. Is this self-pity? I know it might be and I examine it carefully every time it comes up. But no, some bad shit has happened to me in my working life that shouldn’t have happened. Talking about it isn’t self-pity, ruminating on it and sulking in silence would be, but I’m talking about it because I want things to be different for PWPs in the future.
Some of the things that have happened in my working life were bad. The patient who brought a big chunk of broken glass into a session and self-harmed in front of me, the time I arrived at a clinic to find it cordoned off with police tape because there had been a shooting in the car park hours before, and I had to just carry on with the day as planned; the years of nightmares about the gang rape a patient described to me (I tried very hard to stop her but the words were going to come out whatever I said), and so many more incidents. On top of that there’s just the grinding reality of the scope of some problems: domestic abuse, childhood sexual abuse, marital rape, suicidal ideation and action and self harm, poverty and exploitation. My parents and friends vaguely know that these things happen. Bless them, a lot of people who I know turn towards it through voluntary work and community action. The difference between them and me is that they have got the power to make choices about how much a part of their lives this kind of suffering is. I’ve got face after face, voice after voice driving home how much they happen and what the effect is. I haven’t got any say, power or choice in how much of my life is effected and the volume is vast, coming from literally thousands of voices and stories, and that’s just from my clinical experience. Knowing that, I also know how little is done to relieve all of that suffering.
In my first months as a PWP, during my training, an older adult came to see me. They were complaining of frequent headaches and had what I would now call chronic head pain (the pain in their head was persistent and couldn’t be treated). They described that sex made their head pain worse but their partner refused to take no for an answer and would have sex with them even though they didn’t want to (my patient didn’t say ‘rape’ and back then it didn’t occur to me that was what was happening). This made the pain worse and my patient was seriously thinking about suicide being the only way out. I hadn’t had my safeguarding training but the University had told me how to do a risk assessment. This person had thoughts, a plan and intent to end their life, and there were no protective factors. They had to go home because there was no where else to go. I panicked. I went to find a GP. All of the GPs in the building were in a meeting so I walked into the room and explained that I had a patient who I was worried about and could someone talk to them because I didn’t feel safe to end the appointment until they had help. One of the practice partners barely supressed their irritation and told me ‘with all of your wonderful skills I’m sure you can manage’. I put the patient in a taxi to A+E. When I checked the notes I was relieved to see that they had seen someone helpful at A+E who had done a better risk assessment and put them in touch with domestic abuse services and followed proper safeguarding reporting procedures. My patient declined to talk to the police but got effective help.
All of these things are indelibly part of my experience now and are part of how I see myself and the world, and how the two of us fit together. I’m not unhappy about who I’ve become, I’m proud of the things that I’ve achieved, I’m grateful for the education and the experience that IAPT has given to me.
But we can do better than this. As a PWP you’ve also got the tension between the repetition of the High Volume, Low Intensity mantra with the reality of daily working life. They don’t match, but in some teams there’s a kind of gaslighting where PWPs who talk about the difficulty and severity they see in their clinical work, and the effect this has on them, are almost made to feel like they’re being dramatic or imagining it. ‘No your job is low intensity, you see lots of people because you see people who don’t have severe problems. If you’re seeing people with severe problems then you’re doing something wrong…’. NO! The PWPs are not at fault. Our system is relentless and PWPs are cushioning the effect of this with themselves.
During one particularly difficult time I did end up taking a month off work with stress, about seven years ago. At the time my manager suggested that maybe I wasn’t suited to this field of work. That was their solution – that I couldn’t hack it. There was no discussion about any changes, further training or more effective supervision than one hour a week case management that was conducted at a desk in the open plan office. It can’t carry on. We need services to give PWPs power and choice in their working lives and for our service targets and ways of delivering step 2 to be flexible enough to accommodate this. We need services who take PWPs seriously when they say ‘I don’t feel safe’ or ‘this work is having a bad effect on me’. Not to coddle but to empower and support and yes – do the bloody risk assessments and take steps to protect the precious and diminishing resource that is the low intensity workforce.
There aren’t any quick solutions but I plan to write the next blog about supervision and sources of support (and I won’t just be suggesting that PWPs should practice better self care). Two blogs in one week does feel self indulgent but this one has been writing itself for about three weeks and I couldn’t sleep until I got the last bits down tonight. This wont be the last time that I write about vicarious traumatisation but I’m trying to get a balance between the good bits and the bad bits of the job. If you feel affected by anything that I’ve written please reach out for support to any trusted friend or colleague and take care of yourself as a priority.