James Spiers is the guest writer of today’s post. James is a reoccurring writer on notaguru.blog and his other excellent posts are here and here. When he isn’t writing James is a trainee Counselling Psychologist at York St John University currently researching barriers to mental health service access for people who hold LGBT+ identities. James is also a qualified PWP, low intensity supervisor and is co-authoring Care in High Volume: A Pragmatic Guide to Low Intensity Psychological Therapy, due for publication with Elsevier Psychology in Autumn 2022 (and we still can’t believe this is actually happening!)
Each person is an island unto himself, in a very real sense; and he can only build bridges to other islands if he is first of all willing to be himself and permitted to be himself.Carl Rogers
It’s been over a year since I’ve had the time or energy to write for the blog. Simple fact of co-writing a book with Liz (notaguru), full-time training and trying to hold down a part-time job in an IAPT service amidst the backdrop of a global pandemic. Not an easy task, but the opportunity to work remotely from home has saved me valuable time and given me a better work life balance. The tragedy being that it’s taken mass death and social casualty from a deadly virus to achieve this.
Covid-19 propelled the NHS digital 5- year forward at warp speed in a matter of weeks with most IAPT services delivering 100% of their clinical work remotely. Digital enabled therapy was thrust on us (willingly or not) and has generated an opportunity to study the costs and benefits for those funding, delivering and accessing services. This is leaving many people worried that the future of digitised therapy may erode traditional modalities and impact on community inclusion.
Between 2016 and 2019 I worked full time as an IAPT Psychological Wellbeing Practitioner (PWP), militantly clinging to face-to-face appointments, opting specifically to work in demographics where the vast majority of patients insisted on physical engagement. High volume face-to-face appointments took a significant toll, particularly as the vast majority of people neither fit into neat problem descriptors nor typically ticked the box for mild-moderate cases. But I loved working in this community and found working alongside the incredible GP teams and their patients rewarding as well as challenging. Less rewarding were the mountains to climb in terms of generating the national outcome targets, these were achieved, but at additional personal cost. Then Covid-19 arrived.
Patients are rarely the source of stress
After the novelty of working from home wore off, the 10 second commute, wearing a smart shirt with jogging bottoms and ski socks for 6 months, I started to get serious about it. I’ve built enough flat pack furniture to rival Office Depot, turned the spare room in my house into a theatre staged with carefully positioned bookcases, down-lighting and precision angling of my laptop to create a new ‘therapeutic frame’. I have become a digital version of a cliché I never intended to be. Admittedly, I like it and it’s certainly challenged my prior assumptions around video therapy.
Remote working doesn’t suit everyone, I know several people who have struggled to negotiate childcare, home schooling and the comfortable space of their living room that once served to wash the working day away is now spent doing risk assessments for self-harm and suicide amongst a times table chart and multiple re-runs of Frozen. I feel a little guilty in saying that my personal work wellbeing throughout the pandemic has been the best and most sustained since I joined the IAPT programme in 2016. Granted, I’ve been very lucky to have a private space where I can separate my work and personal life.
I’ve missed the physical contact and energy of my colleagues, patients and the GP teams, but working remotely has provided time efficiency, the ability to see more patients, attend more meetings and I still have time to walk the dogs on my lunch break (yes, I said lunch break). One of the most enlightening reflections throughout this period of increased autonomy is that despite the challenges of working on the frontline of an IAPT service, patients are rarely the source of stress.
Despite an early drop in clinical contact due to reduced referrals at the start of the pandemic, things soon picked up and given the widely reported reduction in non-attendance rates, I’ve delivered more clinical contact hours than I did pre-pandemic. I’ve also dealt with higher levels of distress, navigating frequent assessments involving serious risk, traumatic loss through Covid infection and the impact on long-term ill health for those recovering from it. Yet, my work wellbeing has remained intact and my Recovery Rate® has been sustained above the national average.
Recovery Rate®: determined by IAPT caseness on Minimum Data Set, not to be confused with subjective reporting of wellness.
My training placement in a Community Mental Health Team (CMHT) has also been mostly remote due to the pandemic. With some initial hesitancy, the majority of my patients have adapted well, we’ve built strong relationships with surprisingly minimal drop out. The Multi-Disciplinary Team (MDT) meetings and morning handovers via remote access have more or less been ‘business as usual’. Despite these regularly fuelling clinical debate, still navigating resource, still wading through waiting lists, I’ve remained connected. What I’m meaning here, is that the content of discussion is nearly always focussed on patient care. Naturally being in a CMHT I’ve heard some difficult things but have yet to hear anyone mention the words ‘caseness’, ‘data set’ and Recovery Rate®, nor has anyone been asked to put posters up in the local Tesco to bump up the access targets.
Silencing the institutional cyborg
Since working remotely in my IAPT role, I’ve started feeling what I can only describe as less institutionalised. An opportunity to fully recover from the years of relentless pressure I had acclimatised to. Working in any service funded under the IAPT programme there is a constant background noise around access and outcome targets that disseminates to the front line. The more pressure in the system, the volume of that noise increases. When systemic pressure reaches boiling point, the noise becomes deafening, drowning everything else out.
Soon after completing my training year, I remember expressing my unease with the juggernaut we call ‘the IAPT system’. The analogy I described was the Harry Harlow experiments. Granted, it was a pretty long winded, unnecessary and overly intellectualised attempt to explain the dynamic. I often felt that ‘the system’ was a mechanical wire mother covered with a towel and a heat mat. I was the Rhesus monkey, just about managing to feel sufficiently nurtured to remain close to it whilst the mechanics of the system were cushioned. Once the pressure ramped up around Key Performance Indicator’s (KPI’s), the towel fell off, the heat mat went cold and I was left clinging to a painful wire mesh, shouting about how awful it all was. My manager at the time kindly sat and smiled empathically, nodding politely the whole way through, but had their hands tied in terms of what could be done about it.
Fast forward a few years and having matured in the role with a deeper understanding of the system, I now draw on an image of a cyborg in the movie Terminator. While the going is good the system looks, moves and speaks like a human, at least I can partly convince myself of this on most days. Once the bullets start firing at it over performance and KPI’s, the human-like flesh becomes pierced, revealing the show no mercy data management programme underneath. We are then left trying to seek safety by either appeasing it, shouting at it, or distancing ourselves from it.
Since working from home, I’ve had more space to reflect without the volume of that background noise. I’ve come to accept that the cyborg doesn’t hear me when I shout at it, I’m done trying to appease it, but I am more able to distance from it. By becoming remote in both a physical and digital sense, I can do what I do best, the best that I can do it, for whom I can do it for, nothing else. I’ve been able to better focus on the work with my patients and supervising trainees (what I’m paid to do) and for the most part simply delete the 100’s of emails and requests where the focus is not directly related to patient care, rather the management of discharged anxiety from reactive political systems (what I’m not paid to do).
The problem, and I anticipate is the problem for many PWPs, is that no matter how firm the boundaries that we attempt to set at a personal level (pushing back against pressure to increase already excessive clinical activity, speaking out about poor wellbeing, impact on patient care from under resourcing and refusing to limit patient choice in order to manage wating lists), we are often met with further pressure from the system where it then becomes more stressful to maintain the boundaries than they were originally intended to avoid.
Of course, we are rewarded for our efforts with a pat on the head for being “flexible”, but inevitably asked to do further still, based on the fact that we have previously proven “resilience” to work beyond our capacity. For me, the repeated pattern of burnout, relentless focus on data, consistent challenges to being able to work ethically and the visceral awareness of knowing that I’m 3 years past my shelf life in mainstream IAPT, I’ve thrown in the towel (and the heat mat). Enough is enough.
Where have all the PWPs gone?
Although my preference for clinical work has always been face to face, becoming remote has made me realise how heavy the burden of systems issues can be that we unnecessarily carry as PWPs. As much as it grates against my values to have felt happy as a result of the limitations on face-to-face contacts, working remotely has (for me) made the PWP role manageable (just!) By manageable I’m meaning high volume care in a high-pressured system whilst protecting my own wellbeing. A twitter poll of PWPs last July indicated that I’m perhaps not the only one who has experienced this.
It will no doubt be worrying to patients who have not taken well to remote therapy, particularly as there may be a growing trend in PWPs wanting to work remotely after lockdown.
Anecdotal chatter behind the scenes suggests there may be early warning signs for IAPT services in terms of the road ahead. Many services have seen large amounts of PWPs leaving their contracted posts (at least this is what I’ve heard). There is also a significant rise in referrals forecast as we start to re-open society. This is supported by the increasing flurries of job advertisements for qualified PWPs. For those of us who at one point signed up to the mailing lists for agency and locum work on the ‘I’ve almost had enough of this’ days, will currently be receiving regular requests for ‘urgent start’ 3 months, 6 months+ fixed term contracts for various services up and down the country. The majority of which is remote working.
So where is everyone going? I don’t have the answers to this, nor do I suspect IAPT services do either. Speaking only for myself, I recently made the decision to resign from my contracted NHS post after 5 years of working in mainstream IAPT. I have decided to hightail it to independent practice through a digital provider. Here, I guarantee them a small minimum number of hours, secure permanent remote working and gain autonomy over my days, hours, times, choice of work and caseload. The trade-off being that I lose financial security and continuous NHS service.
This wasn’t an easy decision to make, despite my significant unease with the IAPT model more generally, I’ve always valued working in the NHS. IAPT services are also staffed with some incredibly talented people. I will obviously continue with training placements in the NHS and will still work with NHS patients, but I will miss my IAPT colleagues very much. Amongst the sadness, grief, hovering around the ‘send’ button for a month on my resignation email, vivid images of it all going wrong, worrying about paying the bills, is the unescapable experience of feeling like someone has removed a dead body from laying on my chest.
Service models vary wildly across the country, some already offering remote working options pre-pandemic. Variety of working practice for PWPs has also been part of the guidance for IAPT services to avoid staff burnout for quite some time (and I’ve previously militantly fought against this – to my detriment). Given the unenviable demands placed on both service managers and clinical teams, my guess is that the systems involved behind the scenes in IAPT services have always, and will always drive attrition, despite the mammoth efforts of equally frazzled managers trying to cushion the wire. As lockdown starts to lift and the reality of returning to the office looms, are other PWPs considering becoming remote to quieten the mechanical grind of the system?
Greater flexibility in working practices may offer a compromise that helps to retain people in the role, but there needs to be a serious change in the culture, not that we haven’t been saying this for the past 10 years! The retention data post Covid-19 may shed a little light on the viability of this. There will also be patients and staff who have suffered during the course of the pandemic as a result of remote working whether this is their preference of access, or lack of access through digital poverty. Retaining some degree of face-to-face as we come out of lockdown will be essential. But can we afford to return to the ‘train-up, wear-down, burn-out’ treadmill of pre-pandemic practice? Who will be left to greet people at the door?
Aside from the feelings of frustration, anger and loss, these are integrated with feelings of gratitude and love. Although IAPT services operate in highly problematic systems, the service teams and staff are typically warm and supportive humans simply trying to do the best with what they have. Some of them are lucky enough to work with plenty of towels and heat mats, others sadly not. I’m also incredibly grateful for the opportunities and learning that I’ve gained over the years in IAPT, I would not be where I am now if it were not for the IAPT programme. Essentially, this is not a hit and run. Nor am I naïve enough to believe that delivering services independent of mainstream IAPT will be problem free.
For now, the experience of remote working throughout the pandemic has shown me a different way of being in low intensity practice that feels more sustainable, but inevitably requires compromise. Having had the opportunity to step back, I have absolutely no desire to return to what was.