Fishbowls and friends: the IAPT Low Intensity training year

I asked Twitter what image best represented the Low Intensity (LI) CBT training year and had some brilliant responses so I’m going to try to track down free images for all of the suggestions and scatter them through the post. @ffpsych (a low intensity trainee who blogs at https://ffpsych.wordpress.com/) tweeted the picture I used as a feature, it spoke to me.

I’ve had a lot of support with this blog post so the first thing is to thank Amy Worrall, a PWP trainee who works in Calderdale and Kirklees IAPT. Amy had the idea for this post and has sent me a steady stream of thoughts and ideas that I hopefully haven’t butchered too badly. Thanks to Liz Kell as well for contributions from the course provider side. Liz is Chair of the North West PWP Professional Network, & BABCP LI SIG, Senior Lecturer in Psychological Interventions & PWP Course Lead at The University of Central Lancashire. I’ve had some input from other LI trainees who all asked to remain anonymous, many thanks to all of you.

the people around you are likely to genuinely wish you well and want to help. Don’t struggle in silence or alone.

I’m grateful for the support I’ve had to write this and if there’s anything wrong, difficult or controversial in here please assume that that’s all me. My position in relation to the IAPT Low Intensity (LI) training year is that I did complete it – my course started in September 2010 as part of the third wave of recruitment for the IAPT programme – and it has been my great and astonished privilege to teach on a LI training course for the last few months. Just in case this post attracts new readers you can read why I don’t talk about Psychological Wellbeing Practitioners (PWPs) but use Low Intensity Therapist (LIT) here.

With anything to do with IAPT it’s difficult to make sweeping statements that are true for the whole profession across the country. IAPT services are different everywhere, and so are the training courses. I’ll do my best to define my terms as I go and to keep things as general as possible. There are definitely a few themes that seem to carry across all of the trainees in all of the regions that I’ve heard from. You can find standards for the accreditation of PWP training programmes here and the Psychological Professions network have got a helpful page about training here.

I’m going to start this post by thinking about what kind of challenges face the current cohorts of IAPT LI trainees and what kind of support might be helpful for them, then go on to answer some of the questions about the training course that came through to me and offer some suggestions for some reading for people who are thinking about doing the course.

Someone suggested that scales were a good image for IAPT trainees, representing the balance between the course and service demands and expectations

Bragging rights

So I always thought that we had it quite tough in the early IAPT years. The courses, and IAPT itself, were still sorting themselves out. We were taught by people who had never done the job, service supervisors had often not completed the training or done the job either, so support to meet the requirements of the course was sketchy.

My most-repeated horror story about my training is from my first day on the course. I showed up at the University half a day late, clutching the complete works of Shakespeare because I had sat the final exam of my Open University course that morning, and promptly humiliated myself in a goal setting fishbowl-style role-play with the course director with the whole cohort watching me. ‘We don’t make you do fishbowls in front of the whole cohort anymore’ is the best comfort that I have been able to offer to my clinical skills groups this year. 

Good enough on this course in this setting is more than enough, be gentle with yourself

But let’s be honest, as stressful and demanding as the LI CBT training year has always been, the current trainees have now got bragging rights in perpetuity – nothing is ever going to top this year. Not if we’re lucky. When I say that they’ve got bragging rights I mean that all of us who are working anywhere in the system around these trainees have got a chance to step up and offer some effective support to a group of people who are facing some unique challenges.

Translating the dislocation

This whole site is dedicated to celebrating the LI role, but also to unpicking the complexity and difficulty of delivering LICBT within the IAPT system. Our trainees have to get their head around this job while completing an intense post graduate qualification that tests their academic ability and clinical competency while inviting them to confront their fundamental values, beliefs and attitudes. A lot of trainees come to the course imagining that the competencies that we teach on the course will flow seamlessly into practice in their IAPT service. Nope. Here’s a quote from an anonymous contributor sent to me via Twitter DM, copied with permission:

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The difference between the competencies-based teaching on the course and the demands of an IAPT service has always been difficult to juggle, there isn’t a quick fix. Most teams are short of PWPs and need every person working at capacity so that they can meet the standards demanded of an IAPT service. Services will do things that don’t fit with the teaching on the course in order to meet commissioning requirements and keep themselves afloat. Trainees are startled by the admin load, additional time needed for risk management and safeguarding, the complexity and severity of the difficulties that they are asked to assess, the utter ‘lack of time to think, plan and reflect in a working day’ (that’s a quote from a trainee). The lived experience of low intensity work is often not what is described in publicly available information and this adds to the stress of those first few months. An image suggested for this post was of scales – representing how LITs have to balance the demands of the course and the service.

It’s a physically tiring year. The standard 37.5 hour NHS working week is not enough time to do your four days in service with one day at Uni and the reading and coursework that will be required. It’s barely enough time to complete all of the tasks involved in a typical low intensity week without the training. You’ll have to spend evenings and weekends working on the course. On top of that LI work is exhausting. I was talking to a colleague the other week. She’s a CBT therapist but worked as a LIT for five years before doing the high intensity training. She recently volunteered to pick up a weekend assessment clinic. After her second Saturday of LI assessments she said she had planned to go for a run but instead went home, ate pizza and was in bed by 8:30. LI clinical work is physically and psychologically tiring and that’s an extra element that you have to juggle in the training year.  

More than good enough

I’ve said repeatedly that the LI role attracts some incredible people. I have to keep reminding myself that being a LIT isn’t a personality type… but it kind of is. Our trainees tend to be highly intelligent, creative, genuine, empathetic, good problem solvers with a stationary obsession (pens and paper, not standing still!) and top notch time management skills. Most if not all have had some experience of depression or anxiety themselves and approach the role with a motivation to do good and relieve suffering. They also tend to be people who expect a lot of themselves.

I’ve heard that trainees are taking a self-esteem hit because they are used to getting 1sts in their academic work and aren’t getting the same results on the LI course. The low intensity training is pass/fail. You have to get 50% on everything to pass. From the course team and service side, we just want our trainees to pass, no one is expecting marks of 70+ on every piece of work and we don’t compare students to each other (no, genuinely, we don’t). The course is rigorous. Good enough in this training year means that you’re competent and trustworthy enough to carry the responsibilities of sensitive clinical work and represent your team and profession to other healthcare practitioners and the public. Good enough on this course is outstanding. 

Spinning plates was mentioned twice. There’s a lot to juggle at low intensity in IAPT

That said, I remember the anger and resentment we all felt when the course director on our training told us that we just had to be ‘good enough’. He said it at least once a week for the whole course (and still does). Good enough wasn’t good enough for us; we weren’t prepared to just pass, we were going to excel and do it to spite him as much as because it would have been intolerable not to smash it. I’ll be honest, the training year broke us a bit and we staggered through the last months on wave of shared crying sessions and cocktails served in fishbowls. You don’t need to get to that point, you can offer yourself some acceptance and compassion. Good enough on this course in this setting is more than enough, be gentle with yourself.

Don’t panic

On the course you’ll be assessed for a lot of things. You’ll be asked to practice public speaking and complete pieces of reflective writing to a high academic standard. Some courses still have exams. There’s likely to be a substantial potfolio of evidence and reflective writing to submit. There will be live observation of your clinical skills with critical feedback, and you’ll have to watch video recordings of your own work and reflect on these in a meaningful way. Your ability to conduct a low intensity assessment and deliver treatment interventions will be measured against stringent competencies that look at what you do and how you it. Your ability and willingness to adapt your work to individual needs, your empathy, resilience and compassion will be judged.

Remember that it’s in everyone’s best interest to get you through the course. Not just that, the people around you are likely to genuinely wish you well and want to help. Don’t struggle in silence or alone. In your service there will be other people who have done the training recently, you will have a supervisor, you will have colleagues with years of experience in supporting trainees to complete this year.  Many IAPT teachers have done the role/still do the role and will bring that experience into how they deliver the course. Above all, as Amy says ‘Be kind to yourself! And support each other’.

What to do in the COVID era?

Quite a few Universities will have two cohorts of LI CBT trainees currently on their courses. One cohort that started in Autumn 2019 and one cohort that started the course (and therefore started working in IAPT) about one week before the Covid-19 lockdown.  These cohorts of trainees will face slightly different challenges and need different things from their IAPT teams and training providers.

Trainees are startled by the admin load, additional time needed for risk management and safeguarding, the complexity and severity of the difficulties that they are asked to assess, the utter ‘lack of time to think, plan and reflect in a working day’

The Autumn cohort Are at the point where their services will expect them to be fully functioning in the role, so are carrying big caseloads and are also currently adjusting to changes to the university assessment and teaching process while balancing the demands of living through a pandemic and juggling changes at home. Most training providers will have moved to virtual lectures delivered live online, or recordings of lectures. There might be changes to deadlines that can feel uncertain. There’s a risk for some trainees that their training will be prolonged; even though it is designed to give more time to settle into different ways of working this could feel difficult. This cohort are just developing skills and confidence in patient work at the moment when they have to move to new delivery methods, while losing the support from fellow trainees and colleagues that is such a lifeline. Some trainees will also have additional uncertainty caused by how their team responded to the stay at home directive. For example a pause in clinical contact for several weeks might cause a lot of worry that the trainee wont meet the clinical contact hours required to pass the course.

https://en.wikipedia.org/wiki/The_Scream

The Spring Cohort Are adapting incredibly well to new ways of delivery. These trainees have had less contact with their service and very few opportunities to shadow their colleagues and see the role in action. This means that they are probably working closer to the model that we teach on the course but some of them will have never met their colleagues face to face. Some will have had the first day in the job at the start of intro week on the course one week before lockdown started. The people who they work with are likely to be distracted and occupied with figuring out a new way of working and managing personal stress, so might be less able to support trainees. The training course might feel like more of a constant and safety net than the service where the majority of support usually comes from.

Services need to think about additional support when this cohort start to pick up a caseload. Could the situation make the trainees feel sidelined or at a loose end? We all need to remember this group are in a new job so not knowing what you’re doing with yourself is normal, but they have no one handy to ask!

Some of the concerns both cohorts seem to have are things like ‘How will I handle a setback? What if I don’t pass?’ ‘How will I produce my tape in lockdown’ how do I get adequate encryption for my recorded sessions?’ The stress of learning how to navigate and use virtual learning and work environments.  

Things to provide for trainees: 

  • Opportunities for trainees to practice clinical skills together
  • Time in work to talk about the course
  • Time for supervisors and other qualified PWPs to do skills practice with trainees
  • PWP meetings to go over questions in service that could include arrangements for shadowing opportunities, supervision and support for trainees; providing ‘personalised PWP support’.
  • When trainees have a clinic for the first time they will need someone to talk to and process with.
  • Trainees (like the rest of us!) need opportunities for informal chats.
  • Clear guidelines on how to record and store clinical work while complying with your organisations’ policies
  • Adequate working equipment and IT support
  • Simple, easy to follow guides on how to use your clinical record keeping system and any electronic platforms that you use for patient contact. This wont replace being able to grab a colleague and ask but it’s the next best thing.

Trainees need joined up support from their training providers and the service that they work in. Everyone needs to be talking to each other and making sure expectations are very clear. Meetings that are held just for low intensity workers are welcomed, so that low intensity needs and concerned don’t get lost or sidelined among other service issues. Reach out to trainees on purpose. Let them know they have support and don’t be shy about giving reassurance – a wise friend pointed out that reassurance seeking is actually safety seeking – provide safety and trainees will thrive.

What’s the course like?

Ok, so we’ve gone over some of the demands of the training year and I’ve talked a bit about the current situation that we’re in. Now lets take it a bit more general and think about some of the questions you might have about the course that aren’t pandemic related. Some people find the course tough going, other people think that the ideas behind low intensity work are so simple that the training could be done in a week. Wherever you fall on that spectrum enjoy as much of it as you can and remind yourself that it’s just a few months.

For anyone who’s got a place on a training course and is itching to get started, what can you do now?

  • Start doing some background reading; things like NICE guidelines, the DSM and ICD 10 for depression and anxiety disorders, some of the texts I list below
  • Your course will probably require some declarative knowledge statements as part of your qualification, try to get these written as soon as the course starts, before you start your clinical work
  • Clinical and supervision hours log. You’ll need to log all of your contact with patients/service users and all of your supervision. Get some spreadsheets started and don’t lose track of a minute that you could count.

Intro week

I think most courses will have a solid block of teaching for the first week or two. Most of the course will be four days a week in your IAPT team and one day a week with your training provider. Except for the first week which is usually a solid block of teaching. This introduces the course and the core theoretical underpinnings of the Low Intensity CBT model and method.  Where I teach we use some of that week to cover clinical risk assessment and to break down the low intensity assessment and teach and practice it piece by piece. Amy thought there were some key things to say about intro week.

What to expect from induction week:

  • To be tired on Friday
  • Lots of interaction
  • Pushed out of your comfort zone but well supported
  • Meet your clinical skills supervisor/tutor
  • Bond with your skills group
  • Learn the OSCE step by step
  • Practice the OSCE step by step
  • Fishbowls – get this out of the way first!

What is a fishbowl?

One of the most difficult things for a lot of people on the course is the element of public performance. When it comes to skills practice there isn’t anywhere to hide. I doubt that many places will still ask trainees to demonstrate new skills in front of a large group, but we do ask people to demonstrate their clinical skills and accept critical feedback in a smaller group setting. Apparently not many courses still use fishbowl role plays (where you do a role play in front of a group of people and get feedback from everyone), but there will be some public practice and you wont be perfect. If nothing else this is good practice for working in an IAPT team where we are utterly transparent about every aspect of our work; it’s good to get used to this kind of observation as early as possible. It also hopefully makes it feel safe to make mistakes, because that’s going to be crucial too.  

Above all remember that although the training can be tough this job is fantastically worthwhile

What’s an OSCE/A1?

There’s a bit of a hurry from the service and training provider side to get trainees ready to see real patients as quickly as possible. The service needs all low intensity hands on deck to keep the numbers flowing, the training provider requires a certain number of clinical contact hours for a trainee to pass the course, the trainees are usually keen to start working and helping people. So the first assessment on the course measures the trainee’s competency to deliver a low intensity assessment interview, and it happens quickly. This assessment is called different things on different courses, we have OSCEs (Objective Structured Clinical Examination), another department calls it an A1, I’m sure there are other names for it around the country. We’re looking at your skills in setting up the appointment, sticking to time, collecting and making sense of the information someone provides, your non-judgemental and encouraging attitude, how you demonstrate empathy and warmth, your risk assessment, your questioning skills, Your use of reflection and summary, your ability to formulate the problem, create a problem statement and goal for treatment and agree next steps. All in less than 45 minutes. No pressure.

An assessment interview schedule from the Reach Out guide

Basically for the first few weeks you want to do nothing but practice that interview. Role play with your fellow trainees over lunch if you have to, pretend that your cat is depressed and practice funneling the information that they might give to you, ask your supervisor if you can borrow the tape of their OSCE and watch it repeatedly… OK, maybe that’s going too far but you get my point. Practice and get that first assessment out of the way. About 50% of your time as a LIT will be sent conducting assessments and a competent assessment makes a huge different to the outcome of treatment for a patient, so you want to be good at it. Practice, practice, practice.    

Finally, NaGs top tips for training:

  • Think of the training and your work in service as separate things, expect discrepancies
  • Accept that ‘good enough’ really is good enough.
  • Work out ways to get support from the people around you but negotiate this sensibly so that no one is overburdened.
  • Get more formal help or support if you need it e.g. from your line manager, occupational health services, personal therapy (this might be available from university student support services or your NHS organization might have staff support available).
  • Read your course handbooks. Read all of them. Read them several times. Can’t emphasise this enough.
  • Do as much of any declarative exercises and background reading as you can before you pick up a caseload.
  • Make self- care a priority and try not to drink more alcohol than usual.

Above all remember that although the training can be tough this job is fantastically worthwhile. The opportunity to be paid to train to do meaningful and effective work using a modality that is coming to maturity and expanding in exciting directions is amazing. Best of luck and let me know how it goes!

Recommended reading

It’s a good idea to be up to date on the NHS long term plan https://www.england.nhs.uk/long-term-plan/

The IAPT manual is essential if you’re going to work in any role in IAPT https://www.england.nhs.uk/wp-content/uploads/2020/05/iapt-manual-v4.pdf

Low Intensity Cognitive – Behaviour Therapy: a Practitioners Guide by Papworth et al gets referenced a lot. As a course team we don’t agree with everything in there (LI behavioural experiments need their own post!) but it’s a useful and readable key text.

The Oxford Guide to Low Intensity CBT Interventions edited by Bennett-Levey et al was key when I did my training and is still very relevant.

Likewise the Reach Out guide is old school but still very useful https://cedar.exeter.ac.uk/media/universityofexeter/schoolofpsychology/cedar/documents/Reach_Out_3rd_edition.pdf

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