This post is a joint effort between four writers. Liz Kell, James Spiers and Sam Torney have collaborated with NotaGuru for today; you can read previous posts by Liz, Sam and James on the guest writer’s page here. The bulk of the words were written by Sam and NaG, Liz Kell gave us direction and her words and ideas are woven in all the way through, James came to the rescue with an alternative perspective to balance things out, his comments are presented as quotes. As always, I’m grateful for the guest writers’ time and brilliance.
A Backpacking Profession
Between completing my PWP training and joining my team as a Qualified member of staff, I was lucky enough to take a few months off to do some travelling across the other side of the world. When you’re backpacking, you answer the same 3 questions over and over again: “where are you from?” “where are you going next?” and “what do you do?”.
Excited at receiving my qualification two days before I left, I was so proud to tell everyone I met I was a Psychological Wellbeing Practitioner. But after trying to hesitantly explain this for about the 50th time, I started to become a bit unstuck. No-one had any idea what I was talking about – “it’s an English thing” didn’t help, as everyone English I met had never heard of it either. I changed to just saying I worked in Mental Health – people immediately assumed I was a Nurse. I eventually, guiltily, reverted to telling people I was a therapist, and my stomach gave a little lurch every time I did. As trainees at university we had it drummed into us that we were not therapists, nor should we call ourselves that. The NHS make it very clear that we do not have a core profession, that even “Mental Health Professional” is a contentious point. So if no-one has heard of us, we can’t equate ourselves against other Practitioners, and even a lot of people that work within mental health don’t know what we do, who exactly are we?
If you look at PWP retention rates, the argument could be made that we don’t really know ourselves, and nobody is sticking around to find out. Worried emails are being passed around in my locality – Is anyone else having problems recruiting? More than 100 ads for Qualified and Senior PWPs on NHS jobs, more and more inventive ways of trying to promote jobs online – at least we all know we could up sticks tomorrow and find a job pretty much anywhere in the country. On the flip side, we’re all inundated with applicants begging to be considered for training, applicants who quite often tell us they see the PWP role as a stepping stone to their future careers.
Only the weirdos stay
I doubt that anyone has really got an overview of what it’s like to work in ‘IAPT’ – with more than two hundred services implementing models that they call IAPT, how do you keep track of the whole programme? – but from where I’m standing it feels like trouble is brewing.
The PWP role in IAPT exists because a huge gap in healthcare provision was identified. IAPT wasn’t (at least not entirely) a vanity project hatched up by a couple of influential Psychologists. The need for effective psychological services with capacity to meet the huge demand in Primary Care was a decades-old problem and there had been previous efforts to solve it, IAPT is just the biggest and most recent. About one in six people in England are poorly with symptoms of depression or some kind of anxiety. The suffering caused by these illnesses might not always be dramatic or crippling, but it is profound, and there are things that we can do to help if the right people are willing to put in the work. You can dig around in the literature and get a sense of how much (how very much) work went into defining the scope and proposing priorities for Low Intensity interventions in IAPT. This job isn’t just necessary, it’s essential. In fact it’s so essential that this country is willing to invest millions upon millions of pounds in training people to do it.
Sadly, a lot of the people who apply to do that training seem to be people who actually want to do something else. The 2020 PWP retention report picked up on the 2015 IAPT workforce census finding that there was a 25% turnover at Low Intensity. The 2020 census isn’t published yet but I imagine that number will have gone up. Of that 25% in 2015 78% went into CBT or Clinical Psychology training. I’ve heard reports from longer lasting PWPs that people look at them askance for staying in the role ‘But you’ve got so much more to give.’ Please. Do you have any idea how rewarding this can be, or how much good this role can do when it’s properly implemented?
The number of people who move on to High Intensity or Clinical Psychology is really fantastic. There are now people working in these roles who truly understand – and hopefully value – just what it is that PWPs do. We are in no way saying we don’t want that to happen, just that maybe they don’t need to be in such a rush to be there. If circumstances were right, perhaps more people would feel keen and able to stay in the Low Intensity role for longer?Liz Kell
Being honest and to avoid ambiguity: we take issue with people not completing their two years minimum before moving on into other roles. Two years is an unofficial but traditional courtesy period. When your qualification is publicly funded it honours and shows gratitude and appreciation for the substantial investments that were made in your training. If you got a PWP training place then people recognised and wanted to invest in your potential. They gave you money, trust, supervision and education. Paid training with a pretty much guaranteed job at the end of it is a privilege not afforded in many places these days, including nursing. It’s done so the NHS can fill massively needed roles and serve local communities. When we take that training than immediately move on to another role without stopping to hone those skills or work with those communities, I wonder what it says about our own values. And aside from this, at two years qualified I was only just beginning to feel like I really knew my role – I am a much better practitioner now than I was then, and colleagues who are also “career PWPs” agree.
It’s tricky, recruitment. You aren’t allowed to offer NHS funded training posts with conditions. ‘You meet all of our criteria on paper and blew us away at interview. You can have this job if you promise to stay in it for three years, if you leave before then you have to pay back the cost of your training.’ You can’t do that, it’s potentially going to trap someone in a job role that is abusive, exploitative or bad for their health, with no opportunity to respond to unexpected life events. Everyone has to have the right to hand their resignation in to an employer who doesn’t meet their needs.
That said, the inescapable fact is that IAPT is needed in Primary Care and IAPT doesn’t work without PWPs, a lot of them. The current haemorrhage of people out of the low intensity role and the constant training, recruitment and integration of new staff isn’t supportable in the long term. There is a personal impact on those practitioners who are ‘left behind’, a loss of support and team cohesion. It’s financially burdensome, and it inevitably affects IAPT service outcomes. At a time when mental healthcare systems are in desperate need of resources IAPT is going to fall down the priority list, especially if huge proportions of the available money go into training roles that are used as disposable opportunities by the people who secure them.
I became tired of feeling like I was a salesperson. I’ve always used an integrative approach to delivering the basics of CBT principles, but was never sufficiently sold on manualised therapy to want to train in further IAPT models. I opted for a profession that I felt gave me range to work with whoever came through the door, but also increased employability outside of IAPT. I used to look around at some of the most talented psychotherapists and counsellors who were either hiding out of the way, or depressed. I didn’t want that as a career. I wanted a recognised qualification that didn’t hold me hostage to a data management system.James
A Tech Support Line
I found a comment on Reddit yesterday that struck a nerve
‘IAPT is like a tech support line, they follow a book and if your issues are anything more than mild anxiety/depression then they’re pretty much useless’R/MentalHealthUK 13/7/21
This hasn’t been my experience of Low Intensity work in an IAPT team but I’ve observed enough sessions to understand where this comment has come from. ‘Fidelity to the model’ (which is often equated with a narrow interpretation of ‘guided self help’) is emphasised from training onwards. Many LI practitioners are frightened that if they aren’t following a self help manual page by page in their work then they have drifted from the theoretical model and clinical method that is encompassed by their role. That isn’t the case at all, I won’t go into that further now, but no. Just, no.
That same fear of drift, that same sense of restriction goes further than individual practitioners thanks to the IAPT standards and punishing KPIs that services have to achieve, even at a time when they are in a Low Intensity staffing crisis. Services need to get every clinical contact that they can from their Low Intensity workforce or risk becoming a ‘failed’ service that their commissioners might choose to replace with a different provider. It has always felt a bit like a conveyor belt; as a practitioner inside the system you have to plant your feet and hold your ground to do effective clinical work. All of that is made worse, and IAPT teams are struggling, because of the difficulty they have in retaining PWPs.
It can feel like a desert
There is nothing wrong with ambition, ambition is a great quality in any area of work. We’re fortunate to attract some highly capable people into Low Intensity jobs. People with vast academic potential, often co-present with all of the qualities that you’d look for in a really effective therapist, and the organisational gifts needed to manage a demanding and multi-faceted workload. We are lucky. What we find though is that there is a mis-match between what these applicants want from their working life and what services are prepared to offer to the Low Intensity role.
Some of the problems are built in; This is the lowest paid job in psychological therapies. Senior clinical and management opportunities are more available than they were ten years ago but not enough to secure the very capable and ambitious people who are attracted to Psychological Wellbeing Practitioner ads. We hear of PWPs who want to start a family and would be able to do that from the relative affluence of a High Intensity CBT Band 7 salary, but not from the Band 5 Low Intensity CBT pay.
Low Intensity often carries most of the burden for meeting access, waiting time and recovery targets. Without very effective line management this can be experienced as a sense of crushing personal pressure and responsibility. For more practice-minded practitioners, particularly those who are attracted to this type of work by a desire to be a “proper”/more relationally focussed therapist, the level of clinical training and short-term nature of the work might feel restrictive and unfulfilling.
As one of the more ‘relationally focussed’ people, it was the sense of never quite belonging that made it hard to be in IAPT. Low intensity can be done in a person centered way, but at times you could be forgiven for thinking you were part of a cult. I left because I felt there was little room for diverse thinking or criticism, not a lack of passion for clinical work, or to put Dr on my Christmas cards.James
To be a PWP is to hone a unique set of skills that are related but ultimately different to other therapeutic approaches. Trust me, do you know how may time we go around “how to bring someone back to the focus of the session” in clinical skills?! Making those skills understood and known to the wider professions in mental health can feel like an uphill battle at times – I’ve heard PWPs described as “the people that do the assessments”, which, you know, doesn’t exactly cover it.
PWPs accumulate hundreds of hours of clinical practice very quickly. They often manage complex, high volume work, supported by supervision that is not adequately restorative. Many PWPs are hurried through supervision training in order for the service to meet the minimum supervision hours recommended by the IAPT manual. They take on that extra responsibility without any reduction in clinical contact hours or financial recognition. Doing all of this, the low intensity therapists in IAPT teams still do not have professional status. Cynically, I sometimes wonder if this is artificially delayed in order to trap qualified practitioners in the system. Without independent professional status it’s more difficult (but not impossible) to practice privately.
The stepping stones
When the idea for this post germinated I was walking next to my favourite river. The imagery is heavy handed but bear with me. We talk about people who use PWP roles as a stepping stone to get to a different destination. Here is what the stepping stones look like when your eyes are fixed on the opposite bank of the river. The path over there carries on in a straight line and there is a café with some lush tray bakes at the end, but not much to see along the way:
And here is what you see when you look around while you’re on the stepping stones:
If you go that way you still get to the Café eventually. From the direction of that second picture I could hear children playing (we used to bring nets down here and dip for frog spawn and pond life when I was little), dogs scampering in the undergrowth. I’d seen a vole nuzzling along by the side of the river a moment before, a heron lives on the lake just past the bend in the river. There’s plenty of good stuff going on over there, taking some time to look around and explore the possibilities isn’t the worst thing I can imagine.
The image is likely to be different for each person. For me, on a good day I could just about see the trees, on a bad day, more like a concrete tunnel. Hence my focus was always across the water on the other side.James
If you’re thinking about applying for a low intensity training post, please think about why, and think about what you’re going to offer as well as what you can get and where it might take you.
Room to grow
When we were preparing for this post two of us shared that we had, at least once each, maintained our ‘core’ PWP roles at full capacity while completing service development and further training, and as a consequence made ourselves so ill that we were unable to work for months. The additional work that we took on enhanced the service that could be provided by the team, but no additional time and no reduction in caseload was allowed to make room for it. Our experience echoes what other PWPs reported in a previous post. I’ve also observed how difficult it can be to have additional life demands and work as a PWP. Fallen ill or managing a Long Term Health Condition? Want to parent your children? Your marriage is in trouble? Caring responsibilities? Want to have a social life? There isn’t always capacity left at the end of a work day to do any of that. People with lives want to work in IAPT and, essentially, IAPT wont let them.
Retention wont improve until IAPT services are given permission to release PWPs from the treadmill so that they can develop in multiple areas of their professional life. Knowing typical PWPs I can only see this paying huge dividends for services who’s offer would be enhanced by the formidable organisational skills, creativity and industry that PWPs typically display.
I worked for various services, some very good, some less good. For the most part, opportunities for progression are insufficient to keep people interested enough to persist in the core role. You are basically relying on dangling carrots or attrition to progress.James
We have now got an apprentiship route into training and qualification. There are schemes to highlight the role to people who do not have undergraduate degrees in Psychology, people who are less likely to apply for Clinical Psychology training at the same time they apply for PWP training roles. There are more Band 6 and 7 roles that offer clinical and operational leadership opportunities to PWPs. Unfortunately I think we need more than that, I think we need a commitment from people who come into Low Intensity work that they will give at least as much as they take, that they will come into our teams and leave them respectfully and after adding value to the role on the way through.
We hear about Psychology undergraduate courses where the PWP role is promoted to students as a job that was designed for them, something to do while they apply for Clinical Psychology training. If you hear of that happening, please tell them to stop it. Two of the authors of this post have got Lead PWP experience and neither of us have got a Psychology degree, possibly one of the strongest attributes that we had as candidates? I’ve read that this was supposed to be an aspirational role for people, quite frankly, like NotaGuru. People with lower educational attainment for whom the status and salary of a qualified practitioner in the NHS would be a high aspiration. Support workers, healthcare assistants, experts by experience (former patent volunteers), those were the people who were supposed to get these roles. Things haven’t worked out that way. I think in many ways we’ve done work that exceeds the original concept for the role, and I’m proud of that. I want us to carry on being able to mature this clinical method and see where it goes.
PWP-dom is now in its tricky teen years: we are no longer the small children of the therapy world who need to be taken by the hand and taught by our trained in other modalities colleagues. So many people have done such great work getting us to this stage: building the evidence base, the materials we use, the courses that train us. But we’re teenagers now, and as teenagers, I think we need to start taking control of our own identity. Rebel a bit, dye our hair, slam a few doors….or whatever else we need to do to decide who we really are.