I’ve been avoiding this so don’t expect anything too polished today. This post has been a tough one to write and I doubt that I got it right. As always, please let me know what you think. A mini content warning: Although I’m going to write about some of the less easy experiences I’ve had in IAPT I don’t plan to say anything explicit or potentially triggering, references might be made to some challenging experiences and if you are feeling burnt out or demoralised at the moment then you might want to skip this one, wait for the next couple of posts which will be more uplifting.
The post title ‘Cannon Fodder’ is not my words, that’s a quote from a colleague describing how they felt the low intensity workforce were treated in their team, three months ago.
I’ve mentioned before that working at low intensity in IAPT is my dream job, but also that it’s had it’s challenges. Over a decade I’ve seen a number of valued colleagues be affected in adverse ways by the work, and many of them have left the profession as a result. There have been a few surveys that have highlighted problems in the system but no substantial changes. The blog hasn’t really tackled this properly so this will be a series of posts.
- Today, I’m going to tell a story. I’m going to tell quite a personal story of vicarious trauma because I thought this would be the easiest way to illustrate what can happen, and this way I don’t throw anyone else under the bus! Today is essentially about describing the problem.
- I’ll set out another post in the next couple of days with summaries of some conversations that I had with people who gave time to talk to me about what they love about this work. The goal is to balance out what I think made me ill with what can be protective.
- In the next week or two I’ll share a guest post from a team of PWPs who are doing some really great work around wellbeing in their team. They’ve written up results from a survey and what they plan to do next. It was encouraging to read that post when it arrived and I’m excited to showcase some good work.
- After that I’ve had a generous offer from an IAPT manager who is going to share their learning about how leadership and management can protect and support low intensity therapists.
The first time I heard about vicarious trauma I was just over one year qualified as a PWP and five months pregnant with my second child. Thanks to my many assessment appointments with people who had symptoms of PTSD I realised that I had a lot of the same signs. I completed an IES-R and scored above caseness. It wasn’t a surprise; the birth of my first child had been complicated, I’d had an ectopic pregnancy during my IAPT training year and I had had vivid waking memories and repeated nightmares about childbirth since I found out that I was pregnant again. On top of that I had frequent nightmares about some of the stories that clients had shared with me in assessment sessions (I’ll come back to that in a moment) and had been feeling increasingly unsafe when I left the house and irritable at home, even before my pregnancy. Like a good PWP I went looking for some self help material and found Overcoming Trauma by Claudia Herbert and Ann Wetmore.
During my time in IAPT I spent hundreds of hours with people who had experienced the worst possible events that you can imagine. Expectations for clinical contacts varied over the years between ten to eight patients in a clinical day with a roughly 50/50 split between assessing patients who were accessing IAPT for the first time and treatment appointments where we offer the low intensity interventions. If we had an empty appointment slot we were expected to fill it, there was no wiggle room to take account of the complexity of the work that we did in that time. When people clearly had symptoms of PTSD I would often hear parts of their story; desperately negotiating just enough information so that I could work out if IAPT was the right service to do further assessment, without eliciting so much information that I would be overwhelmed or hurt by it. Even nine years into the job those negotiations would sometimes fail. When someone has come to an appointment believing that this is the day when they are finally going to tell somebody about what happened it’s very hard to stop them. In one appointment in the last year I very carefully and explicitly asked the patient not to give me any details of the traumatic events that they had experienced so they presented me with a picture of their friend in the aftermath of torture.
I would do those assessments and it wouldn’t be appropriate or safe to to offer further Step 2 appointments. I had to step to CBT therapists who would go on to offer further more expert assessment and, hopefully, some effective support. The IAPT system of waiting list and recovery targets didn’t leave any leeway for anyone to practice self care in how they managed their clinic, it’s first come, first served and see as many people as quickly as possible, but do it with genuine empathy and care or you’re doing it wrong.
A paper by McNeillie and Rose in the Cognitive Behaviour Therapist published earlier this year caught my eye. The abstract states ‘The literature suggests that therapists experience growth and development alongside vicarious trauma through witnessing clients’ resilience and growth’. Hmmm. That healing witness isn’t accessible to Low Intensity staff because we don’t work alongside people with post traumatic symptoms as they experience healing and growth following the trauma. We take a snapshot of difficulty and distress that becomes our frozen image of that person, part of our perception of the world from then on.
The way the stress has manifested for me has been increased irritability, insomnia, tearfulness, increased fatigue, difficulty problem solving, a loss of creativity and severe panic attacks that are limited only to my IAPT working days… Last week I broke down in tears at my desk in the middle of a clinic because my next call was to yet another person who I felt obliged to try to work with who could in no way benefit from what I can offer.An email from NaG to IAPT managers, 2020
Going back to pregnant Nag, nearly a decade ago. The Overcoming Traumatic Stress book was helpful but not in the way that I had intended it to be. Chapter four is titled ‘Issues for Professionals and Carers: Vicarious Traumatisation’. No one had ever, not once, spoken to anyone in my training cohort about the potential risks that are involved when you encounter stories of events that have caused PTSD in sessions where you are engaged with empathy. I’ve included a couple of images of the pages that grabbed my attention below. Those lists blew my mind and, I’ll be honest, made me very angry.
I spoke to my manager and my supervisor about what I was experiencing. My manager had been contacted by HR because so many people in his team had taken sick leave with stress in a short period of time. My manager smiled as he told me that he had explained to the occupational health team that ‘some people just aren’t suited to this kind of work.’ And no, I didn’t punch him or cry. I did have some time on sick leave though.
We know that compassion fatigue and burnout are the result of a combination of personal and systemic factors. We have got to take responsibility for our own health as well as agitating for bigger change when it’s needed. My observation has been that it’s just about possible to balance this work as long as nothing else is happening in your life. Once real life kicks in; caring responsibilities, divorce, pregnancy, unwell children and partners, house moves etc it’s much more difficult to maintain this well in the long term. There have been two times when I realised that it wasn’t safe to keep working; I wasn’t able to offer empathy and was tearful, irritable and anxious at work. At those times it’s essential to take time off. Two of my colleagues left the role after telling me they felt that way, citing compassion fatigue and burnout in their exit interviews.
A few things that have helped me over the years, in no particular order: Always using supervision, and being honest about the personal cost of the work in supervision. Staying intellectually and academically curious about the work (being a massive geek), attending training and networking events whenever possible. Learning to crochet, accessing personal therapy, doing a mindfulness based cognitive therapy course and maintaining a practice, practicing what I preach and using low intensity interventions on myself when needed, regular journaling, prioritising quality time with friends and family, walking in nature at least once a week. Talking to my GP if stress crosses the line into depression. In short, yes, I’ve eaten my mindful pizza and no, it didn’t solve the problem. Very often when low intensity therapists have spoken about the difficulties that they experience because of systems and demands of LI work the response can feel like gaslighting. The onus is placed entirely on the individual to stay well and the other side of the balance is not acknowledged.
Back then my supervisor was understanding and sympathetic. We went over some techniques for managing boundaries in sessions and how to stop patients from disclosing the details of traumatic incidents. We did that during our regular case management supervision at a desk in an open plan office. Before I began my maternity leave I attended a professional forum and explained how shocked I had been to find out about vicarious trauma in this way and what did everyone else do about it? The best advice was from a former counsellor who explained that when she went to her car at the end of the day she ‘left work in her boot’. No one else had any concrete ideas. A few years later as a Senior PWP I was given half an hour to present on vicarious trauma, compassion fatigue and burnout at the same forum. When I was preparing my presentation the material that resonated and seemed most relevant came from material designed to support first responders at disaster events.
All of that was nine years ago, things have improved to some extent. But (you knew that was coming) not enough. There have been wellbeing initiatives in IAPT; In the last two to three years managers started to talk more about team lunches (not longer lunches of course, this is the NHS after all, 30 unpaid minutes is generous on public money), mindfulness, resilience and taking annual leave. We’ve covered that previously on this site. The NHS leadership academy acknowledges the human cost of caring work because these problems aren’t exclusive to IAPT. In fact I think we’re privileged in IAPT because we do get regular time with a supervisor to review our caseloads, many physical healthcare staff work with bigger caseloads and less supervision.
From my experience, and what others from around the country have described to me, the safety of the Low Intensity workforce varies wildly from one service to another. A trainee who has worked in IAPT for two months told me last week that they already feel affected by encountering material to do with childhood abuse and domestic violence in their clinic. We are at the mercy of local managers and systems. Our expected caseload, the nature of the work that we are expected to do in our clinical time, systems for screening who we will assess for IAPT intervention, the nature and quality of supervision, the esteem that our profession is held in and how valued we and our work are… so much of it comes down to local decisions and culture. As far as I know we still aren’t talking about the risk and prevention of vicarious trauma on low intensity training courses.
Ok, all of that being said, would I go back and not train in low intensity work? Nope, I’d still do it because I love this job, I love the people who I’ve worked alongside. I’ve been humbled and inspired by my patients and I’ve seen healing happen, hundreds of people empowered to manage things differently in a way that they found helpful. Things could be better and safer though, and I hope that we will see more substantial improvements over the next few years.