Resilience: it’s time to change the conversation

James Spiers is the guest writer on Notaguru.blog this week. James is a Low Intensity Therapist (LIT) and trainee Counselling Psychologist at York St John University who speaks passionately about LIT wellbeing and has been a generous friend to this blog since it started. You can find him on Twitter @JamesDspiers and his previous post (the most viewed on this site!) is here. Thanks for another great post James.

The majority of us have come across the term resilience at some point and if you work in an IAPT service, it’s a term you will hear repeatedly.  For the most part, it’s become a mantra within the national discourse on NHS staff wellbeing, or more explicitly put, poor staff wellbeing.  Whilst it’s unlikely (given the pandemic of stress related sickness in the wider NHS workforce), that burnout is somehow unique to Low Intensity Therapists (LITs), we really do need to talk about resilience in IAPT.

What is resilience?

In a nutshell, resilience is the ability to ‘bounce back’.  It’s a concept used in various contexts and settings. From young people learning to live with and integrate the smooth and sharp edges of life, navigating relationships, loss and identity exploration to adult psychological distress and being able to manage, cope or recover from adverse circumstance. 

It would then be a logical and fair assumption to make that ‘resiliency modelling’ in the face of stressful working experiences is a well-meant and potentially useful concept to support LITs working in a high-demand-high-burnout role.  Certainly for LITs undertaking training, learning to build and manage caseloads, working with risk and adapting to the day to day demand of primary care, the term resilience is highly applicable.

The wellbeing business

Rapid rises in mental health problems in the UK have propelled primary care psychological services into a competitive market place, with services under ever increasing pressure to achieve access and outcome targets.  This is paralleled by substantial cuts in funding for secondary health and social care services, leading to increased referral to IAPT services for people experiencing complex difficulties. Despite substantial investment in recruitment and training of new LITs, the retention of qualified staff remains highly problematic.  The end result is a vicious cycle of high pressure within the system, an inability for systems to problem solve, problems passed to frontline staff resulting in low recruitment and retention, ultimately increasing pressure in the system.  

LITs are simply not finding the time to come up safely for air.

SMART goals?

Recent amendments to the IAPT manual include subtle but significant changes for LIT clinical contact hours. The move away from hours ‘offered’ to hours ‘delivered’ also stipulates that services should limit overbooking.  Initially, this was hailed as responsive systems trying to protect LITs (mostly from poorly managed services).

Given the high non-attendance (DNA) and drop-out rates in IAPT services nationally, achieving the [guide] target of 20 hours of clinical contact delivered, means that in many services, LITs are now responsible for making up the time lost from patients who don’t turn up or cancel. In real terms, in order to meet their targets, LITs are now chasing moving variables they have no realistic way of achieving without significant overbooking. For an organisation who advocate so heavily for CBT, it bears little resemblance to a SMART goal.

Essentially, IAPT services appear to be following the lead of the modern budget airline by double booking seats to ensure capacity.  The main difference being, that an airline will offer an alternative flight and crew for over-booked passengers due to airline safety regulations.  Sadly, after 12 years, LITs remain unprotected by any such regulatory body.

Given the DNA rates in IAPT services, a popular argument is that LITs are unlikely to work in excess of their 20-hour guidance.  However, situate this within the context of increased complex referrals, delivering more clinical time than they are allocated per appointment, overbooked patients attending and additional administration they have no time to complete, LITs are simply not finding the time to come up safely for air.

Anxiety in the system … creates a cycle of fixed situational stress with little opportunity for change, perpetuating poor staff wellbeing and attrition.

Perverse problem solving

Take the example of a local bus franchise who are part of a national brand. They have a target of 100 passengers a day to succeed. Currently, only 50 passengers a day regularly use the service. A passenger survey suggests that numbers would increase if the bus was more frequent, a different colour, and the seats were better tailored. The company is now faced with a dilemma. The national brand is resistant to changing the seats and the colour of the bus, there is no extra money to employ more drivers and they still need to hit their targets for the company to survive.

To resolve the dilemma, the company changes their driver policy instead.  The drivers will continue to be paid for their contracted hours only, but will have to keep driving until 100 passengers get on the bus each day.  The bus drivers burn out and go off sick, passenger numbers decline further so the company responds with a wellbeing notice: “This is a team approach. We recognise your workload makes you unwell, but you have equal responsibility to be well. Build resilience by taking breaks and spending time with your family”.  

I’m sure many will agree that this scenario feels perverse and makes no ethical, financial or human sense. So why does it happen in the health service?

Slide from the presentation by James Spiers at the BABCP Bath conference 2019. Image from https://www.alamyimages.fr/photos-images/pouring-water-glass-overflowing.html

 

Anxiety in the system

Despite published research, staff feedback, anecdotal accounts on forums, professional experience of the role being spewed out in blogs and countless ‘mindful’ activities, little appears to have changed for LITs over the past 12 years. That is, apart from increases in their caseloads, reductions in wellbeing, and tokenistic ‘wellbeing initiatives’. However, the focus on wellbeing inevitably retracts when services become panicked about failure to meet the national standards and have limited options other than to repeatedly displace responsibility to the frontline.

Ironically, patients presenting to IAPT with fixed, prolonged and continuous work place stress are more likely to be signposted to employment services than be offered CBT-based intervention, due to the lack of opportunity for behaviour change.  Anxiety in the system (increased complexity of demand and a lack of organisational accountability), creates a similar cycle of fixed situational stress with little opportunity for change, perpetuating poor staff wellbeing and attrition.

It’s time to talk about resilience in systems

Essentially, if IAPT services can’t take their foot off the pedal in relation to commissioning targets in the face of systemic problems, neither can the LITs.  There is little opportunity for either services or staff to be “happy again after something difficult or bad has happened”.  For the majority of LITs, the “difficult or bad” thing is consistently happening. 

Applying a resiliency model to qualified LITs within the context of such high pressured rigid systems, i.e. placing the responsibility for wellbeing into LITs own hands, both negates organisational accountability for change and places those with the lowest power in a position of unnecessary responsibility and blame.

If we are to stand a chance of making tangible and sustained improvements to staff wellbeing, we need to start building resilience in the system rather than the individual.

It’s time to change the conversation about resilience.

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