This post is a short account of what it’s been like to work alongside counsellors in IAPT as a LIT. It is offered humbly and with admiration. This is probably going to highlight the differences between IAPT services and it ranges a little bit around professional identity in IAPT. Above everything else the intention of this post is to celebrate the astounding work of the counsellors in IAPT teams with particular homage to those who have put up with my questions for the last decade. As usual I’ll be talking about Low Intensity Therapists (LITs) instead of Psychological Wellbeing Practitioners (PWPs). Before I start I’d like to emphasise that this post is all on me; one woman’s opinion. The pictures in this post were suggested by counsellors on Twitter, with thanks to @Glennademeter, @clareslaney and the IAPT workers Cafe for their ideas.
IAPT teams aren’t all the same, in fact I’ve never heard of two that are the same; ‘IAPT’ means different things in different places. In the service where I work we’ve got a large cohort of counsellors who currently offer a model that allows up to 20 sessions with their client (person centred counselling for depression). There is representation from the counsellors on the governance and clinical leadership teams and forums for professional development. I have heard of some IAPT services that do not employ any counsellors, so this will be less relevant for some people. I’ve worked with some counsellors who hold CBT diplomas alongside their other qualifications, they offer an integrated approach, but there can be some massive culture and values clashes between the counselling professionals and the CBT based modalities that are sometimes painful to observe. Many counsellors in my area work part time, some as few as 6 hours in a week so there has been little opportunity for them to be familiar with the IAPT model or the LITs that come with it.
I try to imagine doing the work that I’ve done in IAPT without counsellors available at Step 3. My brain just refuses to imagine it. An article in The Psychologist in 2009 pointed out that ‘There is considerable evidence that social and economic factors – taking poverty as only one – are significant contributory factors to both depression and anxiety. Are people really ill or are they responding to the realities of stressful and difficult lives?’ I offer a modality that often emphasises personal responsibility for emotional outcomes in areas of high socio-economic deprivation, working with asylum seekers and refugees and communities like the Roma Slovak who face racism on a daily basis, and have done so in the context of austerity which stripped away support that used to be available. This would have been hopeless without counsellors alongside us. When the problem presented comes with a need to make sense of how past relationships are still affecting the present, when someone has had recent bereavements, when there is the need to adjust to physical health changes, or a focus on the emotional aspect of the present difficulty… above all people describe a need to just talk, and be heard. A LIT can’t meet that need, but counselling sometimes can.
Being the geek that I am I’ve been reading up on the origins of IAPT. Probably should have done that before now but ten years late is better than never! I was really startled (which is telling in itself) to see that it was always the plan for counselling interventions to be part of the IAPT offer. The focus for the last twelve years has been on training the CBT-based cohorts of Low and High Intensity CBT therapists. I came across a paper by David Clarke that explained this was due to there being a lack of trained therapists in CBT based interventions, not a deliberate decision to marginalise humanistic and psychodynamic practitioners and therapies. NICE always recommended CBT based interventions for anxiety but for depression interpersonal psychotherapy, behavioural couples therapy, counselling and brief dynamic therapy were always on the cards. CBT was just where the ‘manpower shortage’ was, it was never supposed to be superior to the range of interventions that we label as “counselling”. I think many people who have worked in IAPT would be surprised by that.
I had depression and anxiety in my early 20s (pre-IAPT, you’ll forgive me for not being more specific) and went to see my GP. They started an SSRI straight away and put me on a waiting list to see the counsellor who they employed at the practice. 18 months later I was sent an appointment letter. The counsellor who I saw was wonderful, very skilful and knowledgeable; but that 18 months was grim. That was in the days before IAPT. I now realise that I was lucky to be registered with a GP practice that was willing to invest in counselling provision, they didn’t have to. To this day if I need personal therapy my preference is for a humanistic approach.
I nearly called this post The Land Before IAPT. You’ve seen The Land Before Time? It’s a cartoon from the 80s. It was the first film that made me cry at the cinema. Spoiler alert: the cute baby dinosaurs are orphaned, they are hunted by a murderous T-Rex across a barren prehistoric landscape, searching for a fertile valley where their relatives are waiting for them with abundant food. The food they crave is treestars – sycamore leaves that stand out in the wasteland, a bright green against brown and grey. Getting access to a counsellor before IAPT (when you couldn’t afford to pay) felt like finding a treestar. It was life-giving and rare, and you had to cross your fingers and hope that you’d find one before starvation or the T-Rex got you. Technically IAPT is the fertile valley isn’t it? In IAPT there isn’t just an abundance of treestars (counsellors), there’s a variety of food to meet your nutritional/therapy needs.
At a training event last year we had presentations about all of the modalities that we offer in the team. There was a sense in the room that many counsellors felt under-valued by the CBT cohort and the CBT cohort resented being perceived as robotic by the counsellors. The counselling presentations focused on the interpersonal elements of their work, the power of the therapeutic relationship and the specific skills that counsellors use to meet a person wherever they are in their experience and support them to navigate towards change. The CBT presentations all focussed on specific protocols for specific disorders. You could see where some of the disagreements might come in but the CBT lead stood up and eloquently acknowledged the value of the therapeutic alliance in CBT and that seemed to help.
When I started my low intensity training in 2010 (this post is really dating me isn’t it?) the team dynamics were interesting. There were three groups. The first was the Primary Care Mental Health Workers had been around for a few years and seemed to be doing something kind of like what I was being taught to do but not quite. The PCMHs all had core professions in social work or general or mental health nursing. They were in a new role and were there to ‘ provide a range of skills valued by patients and the primary care teams and can increase patient access and choice in this area of [mental] health care’
Why weren’t the PCMHs given the low intensity training and allocated to Step 2 in the IAPT model? One paper advocated exactly that. Well, in my area none of the PCMHs did the full LI CBT training year but they got a two day top up training course. Some stayed at Step 2, some went into management and some did CBT training, that was our local result. My guess would be money played a part; the PCMHs were on a Band 6, two pay bands above a trainee LIT and a band above a qualified LIT and IAPT was always about saving money. Stepping back into the restraints of the LIT role would have been a loss of many of their professional skills so it was good news for us all that they retained their old role and scope.
As well as the PCMHs There were the IAPT people; the PWPs and CBT therapists who had trained on IAPT courses within the last two to three years. And there were the counsellors, all of them were women who had been employed by the Primary Care Trust or individual GP practices, most of them had been working in the area for 15-25 years.
The PCMHs seemed to be going along with things – they’d kept their pay band and were mostly left alone to do what they’d been doing before. The counsellors though, the counsellors were in a tough spot. Their training, experience and modality seemed to be under siege. They had been sucked into an amoeba of a system where everyone was talking about CBT. The newly qualified CBT/High Intensity therapists were offered a pay band higher than the counsellors – something to do with the unions – and PWPs were running around, co-opting the language of therapy to describe work that bore no relation to what the counsellors practiced. It must have felt like toddlers had taken over the nursery.
The most rewarding days that I have spent in IAPT were those when my clinic day happened to overlap with a counsellor. Being in the same building as another member of my team has been rare over the years. There were two idyllic years between 2014-16 when my Wednesday clinic was a full day spent in one building (no lunch time travel, my giddy aunt I was high on the luxury of it!) and one of the counsellors was also there for the full day. We got into the habit of having lunch together every week and our conversations mattered more to me than any other support that was available in work. Amongst swapping yoga stories and catching up on team and family news we would naturally review our morning, discuss cases for stepping, talk about our ways of working. It became an essential part of how I processed the effect that my clinical work had on me. I absorbed ways of being alongside the stories of distress that permeated the week just from observing that lady. What staggered me was the difference between what could be held in counselling and what couldn’t be seen in the rest of the team. An angry young person came to see me for assessment with high scores on the PHQ-9 and GAD-7. I felt that we ought to be able to offer something but our mantra was that we couldn’t do anger work (local commissioning was involved). Without sharing any personal details I gave her my impression of the presentation and my worry that they would end up not getting any help and she immediately saw that the anger was an expression of grief. They had sessions with her and moved to recovery.
Many of the counsellors who I have worked alongside found a way to practice in a way that fit with their training and values around IAPT rather than with it. As LITs we meet far too many people every day who are in distress who we feel should get help from us but who don’t fit the IAPT model. When we discuss treatment options in the team it can often feel like CBT/HI therapists are looking for reasons to turn referrals down. It’s been an ongoing temptation to step people who no one else can help to the counsellors who so often gave the impression that they would try to work with everyone.
There is currently a bit of a push happening to train people in the NICE recommended modalities that were always supposed to be part of the IAPT offer. Although more counsellors in IAPT is a good thing, how it’s being done hasn’t been good for already qualified therapists. Most counsellors fund their own training. That involves years of attending a course, doing unpaid work to accrue practice hours and usually paying for their own therapy and supervision as requirements of the training. Once qualified there is then the extra hurdle, and usually a couple more years of unpaid work, while they gather a portfolio of practice and evidence to achieve accreditation which is a requirement for employment in IAPT as well as most other opportunities. Most of the funded training places for IAPT/NICE approved modalities can only be accessed if you are already employed in an IAPT service, there is no option to self-fund. Getting into IAPT without those qualifications can be very difficult, a classic Catch-22. What about those counsellors who had been working for decades before IAPT came along? What if they were qualified, experienced, and accredited in a modality that IAPT doesn’t want? Some have agreed to do the additional training but some feel a real clash of values with working in a more manualised way. From the outside it looks like a nightmare.
I’ve said before that one of the problems with high volume, low intensity work is that the requirements placed on low intensity practitioners ignores the interpersonal element of the work that we do. When a LIT walks into an appointment we don’t walk in as much of ourselves, a lot of the time it feels like we’re there as a representative of a system. We have constraints of time, what information and ideas fall within the boundaries of our role, the number of appointments that we are allowed to offer in one period of care, we have a pre-determined idea of what the successful outcome of our work would be. We often begin appointments already overwhelmed which limits our creativity, energy, and ability to empathise. Our system fosters anxiety; we’re taught to believe that stepping outside these boundaries could harm us, our patients or our team. We make sense of the problems that people tell us about using a model that they aren’t familiar with. We steer the topics that rise in the assessment and elicit responses that fit with what we’re looking for by using reflection and summaries. We talk about ‘containing’ our patients to fit the remit of what we can offer with our time. Don’t get me wrong, there’s good and essential reasons for all of this and LI CBT is fantastically helpful for a lot of people, but not for everyone. If a patient brings something to us that doesn’t fit with what we are looking for then we can’t make room for that without drifting away from our competencies. The result of all of this is that a lot of our attention and the use of our skills goes into controlling the session and, as a consequence, the person that we are offering that time to.
Sometimes I wonder what it would be like to have a conversation in work where I can be wholly genuine, utterly myself. Where all of my skills and characteristics are allowed to be present. Where the only constraints are the principles of ethical practice, the accountability of supervision, and time. A conversation where I can be with the other person and respond to what they need with everything that I’ve got. I imagine that counselling is the closest that we get to that in IAPT.
Obviously I can only write about this from my observations from a Low Intensity CBT perspective. If any counsellor in IAPT would like to write a companion piece about their experience I would be happy to host it. This can be anonymous if you prefer. Please get in touch with me using the contact form on this site or at @notapwpguru on Twitter.