In September 2020 I asked Qualified Psychological Wellbeing Practitioners (PWPs)/ Low Intensity Therapists (LITs) to get in touch. The plan was to write a post about burnout in Low Intensity work and, as someone who loves doing LI work, I wanted to balance that with a post about what makes this a dream job. Several people got in touch; Gemma Hulme was one of the respondents and her post about a service-level wellbeing initiative went onto the site in December 2020. I shared an account of burnout, and Dr Sarah Watts contributed a fantastic post on compassionate leadership late last year. You can read those posts by clicking on the blue links.
To round out the series, today’s post brings together my notes from the conversations and emails that I swapped with three Qualified PWP/LITs called Laura, Kelly and M (who requested anonymity) last year. They’ve all had private apologies from me about how long it has taken to compile this post but I’ll say it again: Thank you for your time, and for your patience with me while this was written up! I would also like to thank the Senior and Lead PWPs who responded and offered to talk to me. I wanted this post to focus on the Qualified role but it’s important to acknowledge that there are a lot of IAPT Low Intensity staff who love their profession.
There is a TLDR bullet list at the end of this post if you find that it’s too long to read.
The Low Intensity Therapists
Laura works in Cumbria and has been qualified as a Low Intensity Therapist since 2018, she ‘fell into this job by accident’ but now speaks passionately about how glad she is to have made this her career. Laura works in the NHS and has a clinical contact target of 7.5/day. she has qualified as a low intensity supervisor.
Kelly has also been qualified for two years, her work experience was in a third sector organisation before moving to the NHS in West Yorkshire. She originally aspired to complete CBT training but has found low intensity work so rewarding that she is tempted to stay in the role for a while longer. Kelly’s target is three assessment appointments and two treatment appointments in a day and she is allocated work time to develop projects based on her interests in physical activity and LGBTQ+ engagement.
M practices Low Intensity interventions in a prison setting, working for a third sector organisation. They qualified in 2016 and offer around four clinical appointments a day. This setting means that ‘the work [is] different every time. Often LI work with a PWP in prison is the first time these individuals have engaged with any form of mental health service’. For M it was important for LI work to be delivered as part of a multi-disciplinary team.
When it works, it really works
‘It’s exciting and interesting’ Laura told me when I asked what she liked about Low Intensity work. She described undertaking supervisor training, support from managers, who have an infectious ‘passion to make changes’, to do an audit of the population groups who access her team and opportunities to ‘go out and do outreach’ in response to the results. Working with interpreters was an ‘exciting challenge’ that allowed her to ‘improve and maintain skills.’ Compared to previous roles she felt ‘supervised to the max’ without that crossing the line into micromanagement. A regular part of her supervision is to review patient feedback on her work, she had many comments from people who are happy with the service that she provides, and it felt good to have that acknowledged by her supervisor.
M picked up on the need for variety in the working week, they emphasised how valuable it is to have ‘opportunities to be involved in other projects not directly related to the role.’ Knowing that they and their role are valued by service managers also matters; ‘I have also been asked to contribute to service design and been allowed to implement suggestions’.
Special interests are essential for Kelly who said ‘I feel burnt out without them’. She has developed a programme of fun exercise with a physical activity instructor and has been given time to think about access and engagement with the LGBTQ+ community. We acknowledged that some services don’t allow this kind of time or flexibility. In some places there is only scope for project work that is linked to specific CQuin targets. For Kelly it had to be work that she cared about. ‘It’s time to do something that I enjoy… seeing it in the diary breaks up the day and I think ‘I’m doing this, and this is good’’. Everyone agreed that you sometimes have to take the risk and ask for the time to start a project like these. ‘You have to put yourself forward’, ‘if you don’t ask, you don’t get.’
M enjoys the intellectual challenge and the creativity that LI work demands; ‘the clients I work with always present in interesting and often complex ways which makes the work different every time’. For Kelly the developing research evidence base and literature around LI work is an attraction. ‘I stay up to date with my reading, then when I’m talking to someone I can say ‘we do what a load of lovely people have said is the best thing for this’’. This interest had an affect on how clinical sessions felt ‘I’ve got time to think about patient work and that means that I can bring initiative and creativity in clinical work.’
Not A Guru: Are most of the people who you work with suitable for step 2 interventions?
Kelly: [I quote directly from my notes] hysterical laughter
Kelly: Many aren’t really appropriate for IAPT but we’ll try step 2. I have to think: ‘where will I start here?’. I have that awkward conversation about goals, my competencies, and a really honest conversation about fit and that we can’t fix everything. Not being afraid is the hard part, I can feel unskilled but we do really good stuff.
NaG: How much pressure do you feel from national targets?
Kelly: None. It’s either going to work or it’s not.
When it’s bad, it’s horrid
Laura acknowledged that it is normal to have some bad days but there have been times when difficulties have gone past what is normal. ‘I can work to my detriment’, there can be a reluctance to take time away from work ‘people are interesting and I want them to do well’. There have been times when she has taken work home because of a worry that she was working with people who needed a different level of care. ‘You have to have the confidence to challenge the stepped care model. The interventions work because they’re simple. You go on that journey together. Trickier cases are not what the role is for, more complex cases mean more thinking and emotional labour outside of work’ and she recognises that that isn’t sustainable long term.
Last year I had about 3 months off due to stress. I was putting pressure on myself to ‘progress’ in some way as I had been qualified a number of years. I was/am leading on a peer mentor scheme which involved designing training materials, recruiting volunteers, vetting them, training them, and then supervising them, as well as being the point of contact for others in other prisons around the country. I was also designing and facilitating training in other establishments regarding self-harm and suicide. I was facilitating mental health awareness training around the country as well. I organised an event in a prison for everyone on caseload to attend a fair style event for world mental health awareness day, which had lead to a number of conflicts with other professionals in the prison. This was on top of seeing a full caseload (admittedly not as high as the community) and providing supervision. looking back I see that I was doing too much however at the time I felt I needed to be doing more and was volunteering to support HR with other events as wellM
The first step, not the bottom rung
All three LITs talked about their links and connections to other people. Laura described a service in which many of the CBT therapists had previously practiced low intensity therapies and valued the role highly. This attitude pervaded through the service, including a lead psychotherapist who actively supports the low intensity workforce and demonstrates their value to the service. Kelly picked up on how much difference the local attitude towards PWPs makes. She described how Low Intensity is held in high regard in her team but a Clinical Psychologist in another service asked: ‘what do you know?’ and Kelly felt that ‘you have to not let what others are saying give you anxiety about what you can do.’
A sadness came from the awareness of how many people come into the role with the intention of leaving it as quickly as possible. ‘I’ve got no desire to do high intensity training’ Laura explained ‘I find it sad when you look on Twitter and all the PWPs are aspiring to be psychologists. It’s not seen to be a career in itself.’
Opportunities to stay connected to other members of the team were important. Laura works in a large geographical area where the team are scattered. She had benefited from lockdown because it had reduced what could feel like unnecessary travel; ‘don’t make us drive for an hour to do a telephone clinic’ she laughed. Travel for team meetings was worthwhile though ‘we appreciate and use any time together and stay in touch… there’s a sense that everyone is all together’. M described how the PWP role was valuable in a multidisciplinary team ‘you make a real difference to… the other many teams that work in the prison, due to violence reduction etc’. Kelly valued being able to talk to the other professions in her team to learn more about what they do, this in turn helped her to make better treatment plans with her patients and enriched her own work.
The connection with patients was also a revitalising factor in Low Intensity work. ‘You make a real difference to their lives’ M explained. Laura agreed that ‘it’s the different people who make it exciting and interesting’.
The spinning top
As I wrote this post and remembered the conversations that happened last year another bit of my mind was going ‘this feels very good, but it all takes time.’ This last section is for all of the other ‘yeah, but…’ers who read this.
Low Intensity work in IAPT services can feel like the point where all of the pressure comes to bear. I sometimes imagine IAPT as a spinning top. The top is everything that an IAPT service is supposed to do; it’s the national targets, the local commissioning targets, the expectations generated by your NHS Trust or the company who won the contract to provide the service. Staffing levels, resilience, morale and expertise in the local team also come into play. All of that has to be managed by the decision makers in the service. They’ve got to figure out how the standards and targets are filtered through the people that they have, to be meaningful to the people who will use the service. If you read the stepped care model with a squint you can argue that everyone who comes into an IAPT service, with the exclusion of those needing treatment for social phobia and PTSD, must go through a step 2 treatment before anything else is offered (I could write a whole book about why I hate that interpretation of stepped care). LITs are where the needle on the spinning top meets the surface of the table, with all of that pressure on top of it.
Service management is an immense task and it’s easy to see why, in a system that focuses on numbers delivered, the ‘high volume’ profession in the team will take the brunt. The good leaders provide a shield so that the LITs don’t feel the weight of this pressure. The leaders whose teams struggle to thrive shower the pressure down (that’s the NotAGuru ‘shield or shower’ theory of leadership). Everything that came up in my conversations with these LITs takes time and interferes with the movement of numbers through the service. LITs often aren’t in unions, we haven’t got regulation, registration or accreditation so we haven’t got professional recognition, and it’s a disproportionately young workforce which services are now used to replacing frequently. As a workforce we’re at the mercy of forces beyond our control in a way that counsellors, Psychologists and CBT therapists aren’t.
Good supervision that isn’t purely focussed on case management decisions, being able to say no to holding people at Step 2 when you can’t help them, reduction in the number of appointments when you serve a community with more severe difficulty and complex needs. Socialising and meeting as a team, special interest projects and service development work, outreach and building relationships with other services who serve the same communities. Continuing professional development and training wasn’t mentioned by my respondents but I’ll throw it in. All of that means less time delivering ‘contacts’ which means it’s harder for a service to meet the targets. When you’ve got a small and unpredictable resource of LITs, inflexible targets that are enforced by organisations who don’t give a damn about the local narrative, and endless demand, the temptation is to get blood from the low intensity stone. I’m trying very hard not to use the word exploitation here, did you see how carefully I skirted around it?
Putting the pressure of service outcomes onto Low Intensity is a false economy. If you provide the time and reduce the demands on low intensity work, if you diffuse some of the pressure away from the point so that IAPT can rest more gently with the people who use it, then more people will do it well and do it for longer. I believe that a reduction in targets and an investment of time would lead to huge gains in the quality of the service that is delivered, and in staff wellbeing and patient outcomes. The conversations that led to this post show that it can be done, it would be great to see it happen more.
TL,DR What Helps?
- A culture that values Low Intensity work, and Low Intensity Therapists
- Managers and supervisors taking time to recognise good work and positive patient feedback
- Feeling connected to the team, time with colleagues
- Balance high volume caseloads with low intensity problems, when that balance isn’t possible then reduce the volume of the caseload.
- Allow LITS to say ‘no’ to working with people with more complex presentations and severe depression and anxiety who need a Step 3 intervention (recognising that sometimes LI can produce fantastic results for people with more severe symptoms but the LITs’ assessment should count in decision making and more time should be allowed for thinking, planning and supervision).
- Flexibility to work from home, and when to work contracted hours.
- Some variety in tasks and duties e.g. the chance to work in a screening and assessment team as well as providing treatment clinics.
- The opportunity to take up Champion roles and develop interventions based on valued interests
- Time to do outreach, promote the service and build links with other teams and organisations in the local community. Co-located and integrated low intensity clinics are very restorative when it’s done well.
- Responsibility to team working and shared service outcomes is fine but there shouldn’t be individual pressure from service targets.
- Opportunities to specialise and progression opportunities are essential and must be available to everyone, not just those who have got the time and energy to work beyond the job description.
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