Care in High Volume: A Pragmatic Guide to Low Intensity Psychological Therapy [1 ed.] 032388492X, 9780323884921

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Care in High Volume

A Pragmatic Guide to Low Intensity Psychological Therapy

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Care in High Volume A Pragmatic Guide to Low Intensity Psychological Therapy

Elizabeth Ruth

The University of Bradford, Bradford, United Kingdom

James Spiers

Academic Press is an imprint of Elsevier 125 London Wall, London EC2Y 5AS, United Kingdom 525 B Street, Suite 1650, San Diego, CA 92101, United States 50 Hampshire Street, 5th Floor, Cambridge, MA 02139, United States The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, United Kingdom Copyright © 2023 Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. ISBN 978-0-323-88492-1 For information on all Academic Press publications visit our website at https://www.elsevier.com/books-and-journals

Publisher: Nikki P. Levy Acquisitions Editor: Joslyn T. Chaiprasert-Paguio Editorial Project Manager: Czarina Mae S. Osuyos Production Project Manager: Kamatchi madhavan Cover Designer: Miles Hitchen Typeset by STRAIVE, India

Dedication Liz dedicates this book to her children, Alan and Kara, With all of my love and thanks. James dedicates this book to his family, friends, and colleagues who have supported him throughout.

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Contents Foreword xiii Acknowledgements xv Introduction xvii

1. Low-intensity psychological interventions Elizabeth Ruth Who are you? 1 ‘Low intensity’ defined 2 Something new 3 A bigger picture 3 Who are we, and where did we come from? 3 Barefoot therapy 4 Evolution 4 The land before IAPT 5 No help 5 PHASING 5 Self-help 6 Bibliotherapy 6 Guided self-help 6 Self-help resources 7 Low-intensity group work 7 Graduate mental health workers 8 High volume 9 NICE 9 Stepped care 10 Options 10 Base or apex 11 Who does what? 11 Bringing it all together 12 Evidence, economics, and serendipity 13 Training and competencies 14 IAPT into action 14 Give me the right lever 14 What’s in a name? 14 Informed consent 15 Professional terms 15 Outcome measures 16 High volume and low intensity 16 Outcomes vs experience 17 Predictable problems 17 Stability 18 Really high volume, really not low intensity 18

Low-intensity supervision 19 Social context 19 Expand or exchange? 19 Psychological safety 21 Gaps in guidelines 21 What now? 21 References 22 Further reading 24

2. Defining success James Spiers Key aims for this chapter 25 IAPT: Debating success 25 The business of wellbeing 26 Wrong doors 26 Right doors 26 Locked doors 27 Revolving doors 27 The journey to IAPT: Kasia’s story 28 Urban myths: A panacea 28 Progressive stepped care 29 Stratified stepped care 29 Challenges with progressive stepped care in IAPT 29 Stepped care: My [un] successful experience 30 Evidence for progressive care in IAPT 31 Defining success: Low-intensity intervention 32 Defining success: Routine outcome measurement 33 Psychoeducational groups 33 Individual guided self-help 35 Re-humanising systems 36 References 37

3. Training and competency Elizabeth Ruth Simple and agile 39 What makes us different? 40 Medication management 40 What is in an ‘intervention’? 41 Self-help material 42 Not everybody reads… 43 vii

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Where book and relationship meet 44 Stay in your shipping lane 44 A unifying model 44 Step-by-step 45 On teaching new practitioners 45 Training cultures 46 Manualised training 47 Principles to practice 47 Celebrating grace 47 The social graces 48 Assessing competence 48 SPSR 49 Single-strand versus multi-strand 49 Two options for multi-strand work 50 Implications for ethical implementation 50 Complexity and burnout 50 Differences between high-intensity CBT and low-intensity interventions 51 What is our model and method? 52 Training a profession 52 Can training help with burnout? 53 Some solutions are worse than the cure 53 Don’t be common 53 Types of practitioner 54 The manualised practitioner 54 The free for all practitioner 54 The reflective practitioner 54 Research to practice 54 Exclusion 55 Manualisation as the first step towards integration 55 Problems with ‘free-for-all’ practice 56 Assessment 57 The reflective practitioner in action 57 An effective course of low-intensity treatment 58 Start with an assessment of the presenting problem 58 Use supervision 58 Choose an intervention 58 Keep track of progress 58 Incorporate relapse prevention 59 Facilitated by the common factor skills 59 Reflective space 59 References 60 Further reading 60

4. Working with challenging social contexts James Spiers Key aims of this chapter 61 Between a clinical rock and a socially hard place 61

Assessment challenges in low-income areas 61 Social neglect 62 Social disorder 62 Problems with suitability 63 Anger and low-intensity intervention 63 Anger and IAPT 64 Suitability: People vs systems 64 Case study: Tom 65 Power and prognosis 66 Assessment phase: Tom 66 Second assessment session (treatment session one) 67 Complicated maintaining factors: Barriers to change 68 Dissociated systems 69 Motivation for change 70 The human story of anger and shame 71 Difficulty containing disclosure 71 Reflecting on Tom’s case 73 Adaptations and flexibility 74 Core conditions 74 Problems in supervision 75 Informed care 75 Neglecting and dismissing our own needs as clinicians 75 Reflective exercise 76 References 76

5. The role of low-intensity psychological interventions in physical healthcare Elizabeth Ruth In this chapter 77 Part 1: Defining terms and background information 77 Long-term health conditions: Context and considerations 77 Medically unexplained symptoms 78 Terms used in this chapter 79 Mental health in physical healthcare 80 The IAPT long-term conditions expansion 80 NHS planning 80 What’s a low-intensity practitioner to do? 81 Specialisation 81 Part 2: Identifying themes in this area of work 82 An intersectional lens 82 Patient A 82 Reflect 83 What should we hold in mind? 84 Levels of response 84 Acute illness compared to chronic illness 85 Reflect 85

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Dual-trained practitioners 85 Bridging the gap 88 The elephant in the room 88 Root or rhizome? 88 A breakdown of trust 89 The whole person 90 The body plays a part 90 Culture clash 91 Still in our lane 91 More complicated anxiety 92 Proportionate response 92 The circle of care 92 Integration 93 Part 3: Implementation 94 Getting started 94 Assessment 96 WWIM 96 Since you became ill, what has changed…? 97 Condition self-management and low-intensity interventions 98 Medical management 99 Role management 99 Emotional management 99 In the room 100 More aspects of self-management 100 Differentiating depression from a physical disability 101 Back to basics 101 Reflect 101 Supplementary interventions 102 Acceptance 102 Multistrand interventions in LTC 103 New ideas 104 On kindness 105 Bringing it together 105 Limitations 105 Step up 106 Reciprocal support 106 A possible future? 106 Outcomes 107 What could happen in the future? 108 References 108

6. Working inclusively with gender and sexual diversity James Spiers Being queer 111 Reflective learning task 111 Construction and deconstruction of LGBT identities in psychotherapy 112 ‘Conversion’ therapy 112 Age as a factor in LGBT experiences 112

Social relationships: Power and intersectionality 113 Minority stress modelling 113 LGBT access and outcomes in mainstream UK psychological services 114 Outcomes: Considering therapeutic paradigms 114 The journey to therapy as LGBTQ+ 115 LGBT visibility: Reducing access barriers? 115 Affirmative practice 116 Active inclusion vs inactive tokenism 116 The LGBT champion 117 Common fears: Working with gender and sexual diversity 118 Case study: David 118 Assessment of risk 119 Initial impressions 119 Adjustments to the service policy 120 Session 2: Barriers to engagement (COM-B) 120 Five areas: The right here, right now 121 Complex problem or complex context? 123 Fine-tuning the problem 124 Supervision: Fine-tuning the intervention 124 Session 3: Selecting materials 125 Guided self-help: Standardisation 126 Equality of access vs equity of access 128 Adaptations in guided self-help 128 Deficits vs strengths 130 Sessions 4–8: Outcome and ending 130 Challenges to the alliance: Therapeutic boundaries 131 Reflecting on the work with David 131 Summary and reflective task 133 Next steps to active inclusive practice 133 Reflective questions for individual clinical practice 133 References 133

7. Psychological practitioner wellbeing Elizabeth Ruth Why wellbeing? 137 Mapping the problems 137 High-volume, low-intensity work 138 Recognition, reward, and respect 139 Comparative deprivation 140 Complex work 141 Not a guru 142 Normalising Step 2.5 142 Clinical drift 143 Supervision and reflection 143 Target driven 143 Micromanagement 144

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Progression frustration 145 Consequences 145 What are vicarious trauma, compassion fatigue, and burnout? 146 Trauma 146 Vicarious trauma 147 Compassion fatigue 147 Burnout 147 Sick leave 148 Loss of reward 148 Complaints and whistleblowing 149 Go private? 149 Plugging the gaps 150 Consequences 150 So what are we going to do? 151 Understanding interpersonal elements 151 Handover 151 Acknowledge the burden of responsibility 151 Allow some time 152 Progressing a career 152 Role definition 152 Specialisation 153 Negotiating targets 153 Recognition 154 Gaslight … 154 … Or learn 155 Top tips: Do’s 155 Top tips: Don’ts 156 Finally 156 There’s always room for a sequel 156 References 157

8. Navigating relationships and therapeutic boundaries James Spiers Key aims of this chapter 159 Professional boundaries in human services 159 The mill pond 159 The wing mirror 160 Therapist effects 161 Challenges with engagement 161 Patients who drop out of treatment 161 Relational drift 162 Therapeutic content and process 162 Low-intensity coaches 163 Low-intensity psychological practitioners 164 The laboratory vs home testing kits 165 Clinical drift 165 Upward vs downward drift 166 Intentionality of drift 166 Understanding therapeutic relationships 166 Transference and countertransference 167

Transference relationship 167 Transference 167 Countertransference 167 Case vignette: Jane 168 Navigating ethical relationships in low-intensity practice 171 Exiting defensive practice 172 The relational dynamics of systems 173 Relational challenges in the current IAPT system in England 173 Understanding ruptures in systems: Whose anxiety is this? 174 Navigating relational boundaries in systems 175 The importance of empathic and compassionate relationships 175 Key messages 176 References 176

9. Reflecting on interpersonal practice James Spiers Key aims of this chapter 179 Personal motivation for LICBT training 179 The seesaw of valuing 180 Relevance to low-intensity practice 182 Devaluing between groups 182 Anxiety around patient engagement: The training year 183 Therapeutic working alliance 184 Becoming a low-intensity supervisor and university marker 184 Barriers to the interpersonal alliance 185 Low therapeutic alliance 185 Avoidance and control 186 Cheerleaders 187 The quarterback 189 The reflective practitioner: Compassionate challenge 191 Addressing problems with interpersonal skills 194 Reflections from beyond the Emerald city 195 References 196

10. Supervision James Spiers and Elizabeth Ruth Key aims of this chapter 197 Functions and use of supervision in the psychological professions 197 Line management versus clinical supervision 197 Mentoring versus clinical supervision 198 Leadership versus line management 198 Monitoring fitness to practice 198

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Case management versus clinical supervision 198 Target 1: Access 199 Target 2: Waiting times 199 Target 3: Recovery 199 The function of high-volume case management: Supervision versus leadership 200 Clinical skills groups 200 Contextualising the low-intensity supervisory model in England 200 Variation within the current model of low-intensity supervision 201 Further challenges with the current model of low-intensity supervision 201 Is the current low-intensity supervisory model fit for purpose? 202 So what do we do about the current challenges with supervision? 202 Supervision contracts 202 Recording sessions 203 Upscaling the current model of low-intensity supervision 203 Implementing low-intensity clinical supervision 203 References 205

11. Professional identity Elizabeth Ruth Learning aims for this chapter 207 The tug of war 207 Some outside support 208 Describing an umbrella 209 Not just CBT 209 Towards a definition 210 The power of an acronym 211 Professional status 212 Core professions 213 Progression 213

Direction of growth 214 Imposition 215 Tribes 215 Different, but equivalent? 216 Never alone 216 Evidence-based costs 217 Counselling in IAPT 217 The dawn of a new age 218 Tension in the team 218 Trainee practitioner recruitment 219 The HEE announcement 220 Status and inclusion 221 ‘Oh bother’ 222 Next steps 223 References 223 Further reading 223

12. Discussing international applications Elizabeth Ruth and James Spiers Aims of this chapter 225 The future of low-intensity practice in England 226 Low-intensity interventions in the United Kingdom 226 Qualification and training 227 How will training be funded outside of the NHS? 228 Stepped care as an international model for service delivery 229 The wider world 229 Core principles of low-intensity psychological practice 230 Targets 231 Lessons learned from IAPT 232 Back to barefoot 232 References 232 Index 235

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Foreword The low-intensity workforce is one of the fastest growing and most important parts of the mental health landscape. Since this training route was developed as part of the IAPT program in England, it has been reproduced in Scotland, Northern Ireland, and Wales, extended to cover children and young people using third sector and NHS services. It has been embedded in schools and is now a key part of the provision of services for people with serious and long-term mental health problems. This has been a remarkable achievement in rolling out high-quality training, supervision, and service provision at scale, and this has given a diverse group of people the opportunity to train in evidence-based therapies, who might not have had the chance to access training and career development in psychological professions without this opportunity. I have been lucky enough to be a small part of this, providing lectures and supervision to trainees on the program and then working with qualified low-intensity workforce as part of their ongoing CPD. These trainees and qualified low-­ intensity practitioners are a group of people who have hit the ground running and brought considerable dedication and ability to provide what the authors of this book rightly describe as care in high volumes. This workforce has achieved this to a really high standard while being some of the lowest paid professionals in the field of mental health. As this workforce continues to grow at pace and the principles that underpin it are taken up internationally, this seems like a good time to pause and reflect on where we are up to and how the workforce is getting on and developing. Liz and James have written an absolutely essential book to support this. Both of them have trained as PWPs and remain part of the low-intensity world as trainers, course leaders, and supervisors, thus combining the frontline experiences of a clinician with the ability to step back and think about the bigger picture. This thinking takes into account the needs of clinicians to get the right kind of training, supervision, and support and the needs of patients for timely, evidence-based treatment that takes into account their whole selves as well as the problems that have brought them into contact with services. Having had the pleasure of reading this book and seeing them present these ideas at conferences and workshops, I can say without any hesitation that the book succeeds in providing an invaluable resource to low-intensity practitioners. The authors understand the pressures of the job and provide clear and thoughtful solutions to the many dilemmas that staff will face in their day-to-day working lives. They understand the need to think about diversity and context in the way that therapies are delivered and the value of therapists having the time to stop and reflect on their work to give the best possible opportunities for people to recover and do well. They also offer thoughts for senior staff in the low-intensity world to support their leadership and ensure that the staff they have responsibility for have the opportunity to develop and thrive in what can be a genuinely challenging working environment. I hope you will find this book stimulating, practical, and useful as I did. Andrew Beck Former President of the BABCP and Head of Clinical Heath Psychology in Bradford Teaching Hospitals NHS Foundation Trust

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Acknowledgements Our heartfelt thanks to our first readers, without whose encouragement and feedback we could not have completed this book. Particular thanks to Adriana Nitranska who provided detailed feedback on several chapters and recommended a structure for the LTC chapter. Taf and Walter Kunorubwe were our first readers when it came to matters of diversity and inclusion; special thanks to Taf for introducing the graces. Sam Torney and Kirsty McNeilis provided feedback and comments from the perspective of practitioners, leaders, and educators; their input provided much-needed reassurance that we were writing something useful. Helen Macdonald of the BABCP and EABCT was the first person to mention the phrase “barefoot therapist” to Liz, which brought the book into focus in the first weeks of writing. Pamela Myles-Hooton shared her own substantial experience of publication throughout our journey and has been a mainstay of support. We have also been supported by generous comments and correspondence from too many colleagues to mention by name. You have each helped refine how we were thinking about our topic and the issues around the low-intensity roles, and you all have our thanks. Finally, our special thanks goes to Dr. Andrew Beck for his continued support and encouragement of the low-intensity workforce as well as the valuable guidance he has offered to us both throughout this project.

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Introduction Elizabeth Rutha and James Spiers a

The University of Bradford, Bradford, United Kingdom

We offer a warm welcome and a thank you for picking up our book. Whether you are delivering, managing, or using psychological services, we hope to offer you a perspective on low-intensity psychological therapy that is both accessible and interesting. As you are reading, we encourage you to think about this book as a dialogue written from different perspectives in the hope that this will offer a broader picture of low-intensity practice. Our intention here is not to write a low-intensity therapy training manual or how-to guide. Instead, we draw on our personal experiences of working in the Improving Access to Psychological Therapies (IAPT) programme, as well as utilising a series of fictional patient case vignettes and in-depth case discussions that are based on the common themes and characteristics across our clinical experience. The aim of doing this is to provide an opportunity for deeper learning whilst protecting patient confidentiality. Combining our reflections from realistic clinical practice, teaching and supervising, alongside references to existing literature, we hope to offer you an insider’s perspective. One of the purposes of this book is to highlight that low-intensity psychological interventions are not a rival or replacement for other therapeutic modalities. This is sometimes confusing because we borrow a lot of language from Cognitive Behavioural Therapy (CBT). Low-intensity psychological practice is a distinct way of working that requires different competencies. To practice low-intensity interventions, you currently have to complete an accredited 1-year training programme or an accredited apprenticeship. Once a person is qualified, the experiences of delivering psychological therapy one to one, in groups, and supporting computerised CBT are varied. Most low-intensity practitioners go on to qualify as low-intensity supervisors, which adds another dimension to the role. The people who are typically attracted to the role tend to be deeply compassionate, intelligent, self-aware, and effective. Working with and alongside such people has driven and informed this book. At the time of writing in 2023, the Improving Access to Psychological Therapies (IAPT) programme has recently changed its name to NHS Talking Therapies. Our personal experience outlined in this book pre-dates this change, and we will be referring to the programme as IAPT throughout. We welcome the progression of professional independent structures set up to support IAPT staff and to develop low-intensity interventions beyond the IAPT system. Professional registration became available in 2021, which is a step towards this. Throughout our various chapters, we draw on different aspects of the existing arguments around the IAPT programme; our case vignettes are also heavily situated within a socioeconomic context. Mainly, this is due to the majority of both our careers in the IAPT programme being embedded in areas that were historically linked with deprivation. However, health inequalities are a global problem, and this is no exception in the United Kingdom. There is a lot of evidence, more rapidly emerging due to the impact of the Covid-19 pandemic, that both physical and mental health is disproportionately impacted based on intersections of identity and socioeconomic factors. In recent years, the health, social care, and welfare reforms stemming from government austerity measures in the United Kingdom have led to reduced healthcare budgets, reconfiguration and shrinkages in secondary care mental health services, and increased poverty in areas already impacted as a result of low social mobility. The founders of the IAPT programme claim that it was never intentionally set up to replace existing healthcare services, but was meant to expand access to psychological therapy to the milder end of the spectrum of poor mental wellbeing within England (Clark et al., 2009). However, its implementation in 2008 has been paralleled by cuts in secondary care mental xvii

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health services. The ‘Mental Health Under Pressure’ report (Gilburt, 2015) found that staffing levels in around half of the community mental health teams in the United Kingdom meant that a full multidisciplinary team was not offered. It also found evidence of inadequate provision of crisis services, reduced inpatient bed capacity, and a reduction in social care services by around a quarter between 2009 and 2015. Worryingly, suicide rates in the United Kingdom have also risen throughout that period (Stuckler et al., 2017) and sadly are still rising. This is not to implicate the inception of IAPT as a causal factor here, but to contextualise how IAPT is positioned as a programme against the continual changes in the social and political landscape in which it resides. The IAPT remit is aimed at mild to moderate low-risk mental health populations. Secondary care services are aimed at higher risk, severe, and enduring difficulties. In a climate of increased poverty, disproportionate health outcomes, and reductions in secondary and specialist health and social care provision, people can often move up and down that continuum depending on timing and context. Many people are impacted by the tightening of service criteria and thresholds on both sides. Inevitably, there are many who fall into the gaps between services. Essentially, we have a mental health and social care system in the United Kingdom that is free at the point of access, and whilst there is work under way to attempt to address some of those gaps, currently NHS mental health services are not entirely open (or at the very least equally accessible) to all. Ultimately, the ongoing debates concerning the efficacy of the IAPT programme can land with scepticism as well as damage at the low-intensity coal face where the real work is happening in pressured and sometimes hazardous conditions. However, our intention here is not to try and bottom out the debate as to whether the IAPT programme works or doesn’t work. Naturally, we hold our own individual opinions and to a degree, the way we individually lean into the broader arguments in the public domain differs. What we can offer are our lived experiences of the utility and clinical realities of the role that underlies those arguments, meaning how we were personally affected by them, how they impacted the work we did with our patients, and how we see the gains and harms from them. Whilst we cannot speak on behalf of all low-intensity practitioners, our offer here is to throw our 10 cents into the mainstream of psychological literature, from the coal face. As with all humans, our history and experiences shape our personal worldview and contribute to biases in our thinking. Our personal experiences also influence our values and sharpen the focus of our different lenses in some areas whilst skewing it in others. This is also true of seasoned academics, service managers, and clinical leaders within the health service. Equally, researchers presenting their findings from randomised controlled trials as well as the accrediting bodies who petition for patient choice, ethics, and safety all have their blind spots. They all hold elements of their own personal truths that are inseparably entwined within their personal, professional, social, political, and economic experience. Whether we like it or not, human psychology is a messy and muddy business. Throughout the chapters in this book, you will see explicit references being made to different psychotherapeutic approaches when discussing low-intensity practice. This is intentional and the hope here is to try to demystify the often idealised world of high-intensity therapy for the low-intensity practitioner. We also hope to demonstrate to those working in high-intensity psychotherapy or counselling that the low-intensity practitioner role is not easy and is not simply about handing out leaflets and ignoring the sources of problems, as it can sometimes be portrayed by people who have never worked in the role; partly because it pushes a little at the politics that often dominate the low-intensity arm of the IAPT programme. What we mean here is that our experience of working in the low-intensity role is that it is mostly packaged using language and terminology relating to CBT, which is most likely to deter practitioners who might be tempted to engage in clinical drift away from low-intensity practice into unqualified pseudocounselling and psychotherapy. Our take here, however, mostly stems from our reflections on the problems that we have personally encountered when working in the role, teaching, and supervising trainees. Our take is that low intensity practitioners require a good understanding of clinical drift that is specific to the low intensity approach, as well as an understanding of the interpersonal processes that occur in clinical sessions. This understanding would support practitioners to recognise how interpersonal processes might contribute to clinical drift and provide a rational for why interpersonal elements in the work need to be actively managed. This should enable faster recognition and effective response to clinical drift when it occurs. The current poverty of education in interpersonal processes for low intensity therapists leaves them blind to the impact and risks of interpersonal dynamics and how this may affect the outcomes of their clinical work. It is also our experience that there is a distinct policing in the current low-intensity literature and training in terms of any explicit reference to the interpersonal processes that are common in psychotherapy more generally, and encouragement for inward reflection during the low-intensity training year is typically superficial, limited only to the low-intensity manuals and tools. However, simply stating that your delivery model is low intensity does not eliminate millennia of knowledge accumulated in the broader profession of counselling and psychotherapy. Just because you do not use it, don’t mention it, or prefer to call it by another name does not mean it ceases to exist or that it is not of value. The interpersonal processes that are present in every human interaction, including low-intensity practice, are vital to consider if we are to improve outcomes and engagement for our patients.

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As we hope to relay, low-intensity therapy—offered flexibly and adaptively—can help a large and diverse group of people. Low-intensity practitioners can work at the cutting edge of technology and deliver digital therapy remotely from their homes whilst also offering what looks more like traditional therapeutic work in a community-based setting. However, low-intensity intervention is not a cure-all. There are significant limitations to the depth of problems and therapeutic exploration that a low-intensity practitioner can work with, and low-intensity interventions cannot simply replace existing psychological therapy or health and social care services. Equally, there is also a potential for harm from misusing lowintensity interventions to manage demand in overstretched healthcare settings and services. In our opinion, any notion that low-intensity practitioners are either delivering truly evidence-based standardised care that is paid for through savings in the welfare bill or working as the Uber drivers of the health service hellbent on destroying community engagement falls very short of the clinical realities of the role. Once again, we thank you for picking up and reading our book this far. We are excited about the work and aim to provide an accessible sense of low-intensity psychological therapy and the low-intensity practitioner role whilst weaving in a memoir of our personal experiences. We hope that you will enjoy reading our book and that you find something useful in the following chapters.

References Clark, D.M., Layard, R., Smithies, R., Richards, D.A., Suckling, R., Wright, B., 2009. Improving access to psychological therapy: initial evaluation of two UK demonstration sites. Behav. Res. Ther. 47 (11), 910–920. Gilburt, H., 2015. Mental Health Under Pressure. The King’s Fund, London. Stuckler, D., Reeves, A., Loopstra, R., Karanikolos, M., McKee, M., 2017. Austerity and health: the impact in the UK and Europe. Eur. J. Pub. Health 27 (4), 18–21.

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Chapter 1

Low-intensity psychological interventions Elizabeth Ruth University of Bradford, Bradford, United Kingdom

This chapter provides an introduction to the development of low-intensity psychological interventions in England and their implementation within the Improving Access to Psychological Therapies programme. Using personal experience and highlighting key developments in the published literature, we attempt to track the interweaving of clinical and system developments that brings us to the present day and provides a foundation for the subsequent chapters in this book. Learning aims: ● ● ● ● ●

Considering how low-intensity psychological interventions developed in England Explore the principles of low-intensity psychological practice Understanding the rationale for the implementation of low-intensity practice in a stepped care system An awareness of some of the criticisms and ongoing dilemmas surrounding the system and the approach An opportunity to reflect on the experience of the patient and practitioner within the system.

Who are you? ‘What do you do?’ We have all been asked that question. Most of you can answer it quickly, in a way that makes sense to the people who you meet. I am a builder, a teacher, a biochemist, and I curate a gallery, most occupations are familiar, or at least easy to describe to other people. So now imagine what happens when you say ‘I’m a Psychological Wellbeing Practitioner’. Glazed stares and slightly nervous laughter are good responses. You find yourself starting to explain ‘You know, I’m an IAPT worker, a low-intensity practitioner?’ Your conversational partner starts to look around the room as if for an escape route. In desperation you throw in the one profession that everyone has heard of and use it as an analogy ‘I’m the psychology equivalent of a nurse’. That usually buys you some breathing room. Then, lulled into a false sense of relief and security by the familiar and reassuring word ‘nurse’, they ask ‘so how does that work?’ You grip your glass more tightly and breathe out a slow breath. Here goes… ‘Ok, so in the old days it was really hard to find help if you were low in mood or anxious...’ I started to train as a low-intensity therapist, or Psychological Wellbeing Practitioner (PWP), in 2010 and I still can’t describe what I do in one sentence, not in a way that makes sense to my friends and family. In the summer of 2022, I tried to explain this approach to my cousin, and the best that I could offer was ‘it’s for people who might be feeling depressed or anxious who want some help getting back to themselves. We’re easy to get to, can offer some quick ideas, and we won’t make you talk about your relationship with your mother’. What I have learned in the last decade is that whilst the theoretical model and clinical methods that we describe as low-intensity psychological therapies are very straightforward, practising the approach is not. You want to guarantee that you’ll sleep well after we’ve spoken? Ask me about work because once I start to talk about it, I find it difficult to stop. Low-intensity interventions are exciting, if you look at them from the correct angle (that would be from inside the emotional equivalent of a bomb shelter a couple of miles away from where it’s all happening). As I worked in an Improving Access to Psychological Therapies (IAPT) team and practised low-intensity psychological interventions for over a decade, I became increasingly frustrated by the fact that none of the literature that was published about this field of work described what it was like to do it. There was nothing that I could point to and say, ‘this is what I do’. Published research papers and textbooks seemed to be written by people who had vaguely heard of the idea of what we do or who had got no clue (or didn’t care) about the day-to-day realities of our work. The literature described a sanitised and theoretical version of low-intensity therapies, without the complex overlap of components, that is, the experience of the role in practice. Speakers at our events, those who might have access to publishers and a platform from which to speak, sometimes have a paternalistic, self-aggrandising and controlling attitude. More than once I’ve compared IAPT with a ­feudal Care in High Volume. https://doi.org/10.1016/B978-0-323-88492-1.00001-4 Copyright © 2023 Elsevier Inc. All rights reserved.

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2  Care in high volume

system, with low-intensity practitioners as the serfs working the fields at the bottom of the hierarchy and the academic ‘kings’ at the top. In fairness, this has started to change in the last few years, and the relationship between low-intensity practice and the academy has started to shift to something more respectful and collaborative; an example of this can be seen in the work of initiatives like the IAPT Practice Research Network (2021; Lucock et al., 2017). There is still debate about the language that we use to describe our role, model, and methods. For example, a paper published in 2016 comparing psychological interventions for depression referred to the Psychological Wellbeing Practitioners who contributed as ‘junior mental health workers’ (Richards et  al., 2016), depriving the practitioners of the dignity of their job title. It’s also an inaccurate description; there is an important distinction between ‘mental health work’ and the low-intensity psychological interventions that Psychological Wellbeing Practitioners deliver in the Improving Access to Psychological Therapies teams. So, in an abundance of enthusiasm and frustration, I started to write. This book is our answer to that question ‘what do you do?’ and, more than that, we will describe what it has been like to be a low-intensity practitioner, and what we think this emerging profession could become. This book is more concerned with the nature and philosophy of low-intensity psychological therapies than the ‘how to’ of specific interventions. We, the authors, recognise that our experience isn’t universal; low-intensity psychological therapies are delivered in a number of different contexts and for different purposes worldwide. Even within the IAPT programme in England, there are significant variations in how low-intensity interventions are implemented, taught, and supported, based on the local need and commissioning decisions. Even so, we hope that our experience will give some insights into how we can develop this approach and support the global workforce in future. This chapter will give some context and a short, selective history of our role and introduce the themes that we will explore in more depth in the later chapters of this book. We’ll know that we have succeeded in our aims for this book if, in a year or two, I ask you ‘what do I do?’ and your reply is a broad and hopeful smile.

‘Low intensity’ defined This book will be full of jargon, that’s an unfortunate inevitability when we talk about this field of work. I’m going to kick us off with an attempt at explaining the phrase ‘low-intensity interventions’ and fill you in on the development of the Improving Access to Psychological Therapies (IAPT) programme. ‘Low intensity’ refers to the amount of contact that a patient, service user, or client has with a practitioner during a course of treatment. In psychoanalysis or psychodynamic therapy, a patient and therapist might meet for sessions between one to three times a week, and depending on the model of therapy being used, they may continue to meet for months or years. In humanistic and person-centred counselling, the patient and counsellor typically meet for 50–60 min once a week for a period that can vary between 6 weeks to several years. Cognitive behavioural therapy (CBT) tends to be more time limited, with appointments typically of 50 min (although some treatments require longer appointments) and a typical course of treatment lasting from 6 to 20 weeks in primary care IAPT services, and often longer in specialist therapy services. All of these vary significantly depending on what the presenting problem is. Low-intensity interventions can be accessed in a lot of different ways, and each delivery method takes up different amounts of practitioner time (Table 1.1). But whatever ‘health technology’ is part of the treatment and whatever delivery style is used, low-intensity interventions are intended to be less burdensome than traditional talking therapies.

TABLE 1.1  Delivery methods for low-intensity interventions and contact time with a low-intensity practitioner. Low-intensity delivery method

Contact with a practitioner

One-on-one appointments (in person, by telephone, or via video platform)

Up to 45-min assessment appointment  Up to eight 30-min treatment appointments  Maximum contact time: 4 h, 45 min

Computerised CBT (cCBT)

Email contact with a low-intensity practitioner during engagement with the programme Maximum contact time, approximately 1 h for a course of treatment

Small-group psychoeducation workshop Approx. 8–20 participants, two facilitators

Depends on the design of the course but typically 2–3 h/week for 4–6 weeks Maximum contact time: 18 h

Lecture-style/didactic psychoeducation course, unlimited number of participants, two attendees

Depends on local course design, a typical example is 1.5 h once a week for 6 weeks Maximum contact time: 9 h



Low-intensity psychological interventions Chapter | 1  3

Something new One of the most common grounds for criticism of low-intensity interventions is that they do not do what other theoretical models and clinical methods of psychological therapy offer. This is born from a misplaced idea that low-intensity interventions were implemented to replace other approaches to talking therapy. That is not the function of low-intensity interventions, we provide a new, distinct model that adds to the array of psychological interventions, we do not provide ‘lower’ versions of CBT, or counselling “on the cheap.” The use of ‘low intensity’ as a description for the approach is unfortunate because it suggests a lower place on a hierarchy of interventions and models. Ideally, all psychological interventions would be perceived as equal but different, expanding choice, providing more opportunity to find the best fit between the patient and their presenting problem, and the services that are available. The true meaning of ‘low intensity’ is simply that it involves less contact with a therapist than other approaches, it’s got nothing to do with the hierarchical status of the approach, or how well the interventions work. One of the great benefits of low-intensity therapies is the reduced costs for the patient and for the system that hosts these interventions. Traditional and ‘high-intensity’ talking therapies demand a significant commitment from the patient: hours of emotional labour through in-depth self-examination and close engagement and disclosure with a therapist, the ability to make sense of complex formulations, and often significant travel and financial costs. Low-intensity therapies are designed to reduce these costs to the patient. We also have to consider the cost of providing therapy from the perspective of the therapist, and the system as a whole. In England, the Improving Access to Psychological Therapy (IAPT) programme is part of the offer from the National Health Service (NHS). Care within the NHS is free at the point of access; the financial cost of training, equipping, and providing salaries and benefits for staff comes from the national healthcare budget. The relatively low cost of low-intensity training and salary compared with other psychological therapists is a benefit to the healthcare system that hosts it, with some caveats that we will explore in later chapters. ‘Low intensity’ does not mean ‘low worth’ but lower cost (with ‘cost’ having a broad definition) than other approaches in psychological therapies. After working in IAPT services for 11 years, I understand the low-intensity approach and workforce to be the foundation of our primary care psychology provision, not the lowest rung on a hierarchical ladder.

A bigger picture The Improving Access to Psychological Therapies programme was not the first implementation of low-intensity psychological and wellbeing interventions in a progressive or stepped care system. Low-intensity psychosocial interventions have developed in a number of low- and middle-income countries over the last decades, often in response to high need, such as in the aftermath of war, and where resources are scarce. In particular, school and community-based interventions for children have utilised psychoeducation interventions and nonspecialist counselling (Betancourt et al., 2013; Jordans et al., 2016). This book will have a focus on developments in England specifically; we do not claim that these developments are unique in the world.

Who are we, and where did we come from? Every so often I come across psychologists who seem to be in mourning for the days before the IAPT programme was rolled out. They feel that IAPT is an attempt to homogenise psychological interventions in primary care and has shut down innovation and undermined good quality, patient-centred care. When these comments are made on social media, the replies usually include a reminder that before IAPT, the waiting times for any kind of talking therapy were astronomical, and talking therapy was not offered to most of the people who could benefit from it, no matter how long they waited on a list. The informal consensus seems to be that IAPT isn’t perfect—we are going to dig into some of the criticisms in this book—but it’s a darned sight better than how things used to be. This isn’t a book about IAPT, but it’s a book about low-intensity psychological therapies that can be practised effectively in other care settings. However, James and I have carried out the majority of our low-intensity practice within an IAPT system; IAPT is our context when we write about our work. I’m going to try to describe the olden days before England had a stepped care system for the delivery of psychological therapies in primary care; hopefully, that sentence will make sense by the time we get to mid-chapter. So much work coalesced in the implementation of IAPT and the development of low-intensity psychological interventions that I will have either missed some of the papers that I should have read, or not had room here to include all of the detail that makes up this story. My apologies to anyone whose work is not appropriately acknowledged here.

4  Care in high volume

Barefoot therapy A lot has been done to develop low-intensity psychological interventions in the last quarter century. England’s IAPT programme is possibly the largest scale experiment in making low-intensity interventions available, but there are many other settings where this approach has been adopted worldwide. In fact, our philosophical roots go all the way back to China in the 1960s (Brady, 2016). In 1965 Mao Zedong initiated a programme to train ‘barefoot doctors’ to equalise access to medical care between urban centres and rural populations. The programme acknowledged that most of the population in China lived in rural communities where there were very few doctors with modern medical education. Essentially, there were disparities in the provision of care on socioeconomic lines. The programme gathered local recruits who underwent a short training programme, just a few months, in the essential medical interventions that were most needed in their district: vaccination, nutrition, and curing whatever the most common ailments were locally, but above all their role was in disease prevention. After training, they went back to their communities, able to provide medical primary care when it was needed. Isaac Marks, a psychiatrist and behavioural psychotherapist, brought these same principles into the realm of psychotherapy in 1973, when he developed a post-qualification training course in behavioural interventions for nurses who worked on a psychiatric ward at the Maudsley Hospital in London. This caught the shift in mental health nursing on in-patient wards from observational and custodial to a more autonomous therapeutic role, recognising and utilising the interpersonal competencies that these nurses had. A review of Nursing in Behavioural Psychotherapy: An Advanced Clinical Role For Nurses (Marks et al., 1977) in the journal Behavioural Psychotherapy (Thorley, 1978) describes that ‘adequately selected and correctly trained nurses can achieve levels of clinical assessment and treatment effectiveness equivalent to those already established by psychologists and psychiatrists…’ This doesn’t mean that practitioners with training in a limited range of behavioural techniques have equivalent qualification to psychologists and psychiatrists, it means that they can be as skillful in the delivery of specific interventions as someone with a more comprehensive qualification. Marks and colleagues went on to publish an account of this early work and a description of the first training course for ‘nurse therapists’ in Marks et al. (1977). The nurse therapists who were trained in behavioural therapy would be called ‘high-intensity’ therapists in IAPT, or CBT therapists in other settings. Still, features of this work that felt familiar, and are pertinent to low-intensity interventions: ●

●

●

●

Recognition that a practitioner does not need many years of training to provide safe and effective psychosocial interventions for common mental health problems. The idea that specific skills and core interventions, strategies, or change methods from the psychological approaches can be isolated and taught effectively, without a requirement to become a qualified psychotherapist in the whole therapeutic modality and clinical method (although on completion of the nurse therapist training nurses were recognised as CBT therapists and eligible for accreditation with the British Association of Behavioural and Cognitive Psychotherapies (Gournay et al., 2000)). In an environment with limited resources you have to make the most of what is already available. The nurses on the ward had the essential abilities and interpersonal competencies to deliver psychological interventions, and this hadn’t previously been utilised. It helps if you know what the most prevalent problems are in the target population, and you then focus the training of low-intensity practitioners on the interventions that will address those specific problems.

Evolution I’ll admit that the description of the presenting difficulties on the ward and the behavioural interventions that were offered in those early days makes my hair stand on end. Flooding and electric aversion therapy are not offered by PWPs in IAPT services. The psychological theory and practice have evolved in the intervening decades, and Marks has been a significant contributor to those developments, including pioneering computerised self-help for phobias (Marks et al., 2007). The principles of Marks’ barefoot therapist idea are still current: Train able people in the specific interventions that are most helpful for the problems that arise most often in the therapist’s local community. Training of this type is neither costly or time-consuming (Marks’ first training course was 18 months in duration, IAPT low- and high-intensity CBT training in England is one academic year, approximately 9 months) nor are the interventions that these practitioners offer. The psychological interventions or strategies are as effective when they are delivered by a low-intensity practitioner as by someone with doctoral-level training.

Low-intensity psychological interventions Chapter | 1  5



Training programmes based on this work persisted, and dual-qualified practitioners with general and mental health nursing and social work qualifications who had completed postqualifying training in CBT-based psychological interventions were still around in various settings when the IAPT programme rolled out in 2008.

The land before IAPT It is helpful to put the development of low-intensity interventions into the context of other talking therapy provision. In English primary care before IAPT (our version of The Land Before Time (Don Bluth and Bluth, 1988)), the provision of talking therapy of any kind in the NHS was a postcode gamble. Some GP practices invested specifically in a ‘practice counsellor’. A practice counsellor was a talking therapist who would offer sessions of cognitive behavioural therapy (CBT), humanistic counselling, or psychodynamic counselling according to their training and competence. This would be available to the patients who were registered with that GP practice. Some GP practices commissioned services from a local team of counsellors, maybe 1 or 2 days in the week, where talking therapy would be available to their patients. This generous provision by teams of GPs was lifesaving for many, but not usually adequate to the needs of the patient population. Waiting lists could be years long, and there was little patient choice. If you didn’t find that the therapist or their approach was a good fit for you or your problem, you were out of luck. The Department of Health Mental Health Policy Implementation Guide, published in 2001, described that around 50% of GP practices provided access to counselling services and admitted that access to ‘effective psychological therapy and counselling services is commonly problematic’. Which is a great example of the wry understatement that we should all pause to appreciate.

No help Patients with mild to moderately severe depression and anxiety disorders who were registered in a GP practice that did not have access to a counselling or therapy service would be offered the choice of medication, or nothing. Thanks to a common fear of becoming addicted to medication, amongst other factors, many people declined medication and went untreated (Farrand et al., 2007). The more severely unwell might be put onto an unpredictably long waiting list for an assessment with a clinical psychologist or the local community mental health team, which may or may not include talking therapy in its offer. Most people just struggled on alone. The problem of how to treat common mental health problems in primary care was significant and well documented in the literature by the end of the twentieth century. Approximately one-fifth of primary care appointments were due to a common mental health disorder (Table 1.2).

TABLE 1.2  Common mental health disorders. • Depression

• Stress

Anxiety types:

• Panic

• Generalised anxiety disorder

• PTSD

• Health anxiety

• Social anxiety disorder

• Phobia

• OCD

In primary care, these difficulties will often present with symptoms that are mild enough that the patient doesn’t need hospital care, but severe enough to cause significant difficulty and misery.

PHASING There was a recognition that the burden of treating all of these patients fell on the GP. Primary care nurses and other health and social care professionals reported that they were not trained or competent to work with mental health disorders and would need further training if they were to expand their role to include mental and physical healthcare (Department of Health, 2001). The phase randomised controlled trial (Richerds et al., 2003) found good results with a brief self-help programme for depression that primary care nurses could deliver across three appointments, but ultimately, there was a problem with capacity; demand far outstripped provision; and the workforce needed to be expanded.

6  Care in high volume

In 2000 the Department of Health issued the NHS Plan (the Department of Health, 2000), a substantial document that highlights areas for reform and improvement in the NHS, quickly followed by the Mental Health Policy Implementation Guide (the Department of Health, 2001). The Mental Health Policy Implementation Guide explicitly recognised that psychosocial interventions can be successfully taught to staff who do not have a mental health professional qualification. It also proposed a role for ‘new mental health workers’ (p.69), envisioning a role for recent psychology graduates in primary care mental health (Lucock and Frost, 2004). This idea was developed into the training of Graduate Mental Health Workers, more on them in a moment.

Self-help The earliest example of self-help literature is possibly the book Self Help by a Victorian doctor called Samuel Smiles, first published in 1859. The original Self Help was a manual that promoted self-reliance and the development of personal character along specific lines, addressing attitudes of perseverance and hard work, social status, financial management and specific gender roles and attributes that, predictably, feel old-fashioned to a 21st century reader. The self-help genre has progressed since then. In the field of mental health services, when we say ‘self-help’, we usually mean health technologies like books, computer programmes, and audio material that present methods of treatment for depression and anxiety disorders in a way that would enable a patient to learn the treatment method and use it on themselves. The material in these packages is usually based on cognitive behavioural techniques. CBT, of all of the approaches to psychological interventions, relies on ‘specific factors’ to produce change. That is, it is not the relationship between the therapist and the patient that helps the patient to feel better but the specific ideas and techniques that the therapist teaches to the patient, and the patient’s self-practice of these techniques, that produces change. Therefore CBT, of all of the approaches to psychological therapy, is most easily ‘manualised’; it can be written down in an accessible way so that the principles and techniques can be learned and used independently.

Bibliotherapy With the demand for treatment for common mental health conditions far outstripping the provision of qualified therapists, one potential answer to the pressure on systems was bibliotherapy. By the second half of the 1990s, several studies had shown that self-help could be an effective intervention for depression and anxiety (Williams, 2001b). There was enough evidence for NICE, in the 2004 CG22 guidelines, to recommended that patients with panic disorder and generalised anxiety should be offered a selection of treatments in primary care, one of these was ‘self-help (bibliotherapy—the use of written material to help people understand their psychological problems and learn ways to overcome them by changing their behaviour—based on CBT principles)’. ‘What is new in this treatment modality is not the content because bibliotherapy usually uses a cognitive-behavioural approach. Only the form in which it is presented is new. In bibliotherapy, the patient takes a standardised treatment home, in a book form, and works it through more or less independently. Contacts with therapists are only supportive or facilitative. No traditional relationship between the therapist and the patient is developed’ (Cuijpers, 1997).

Although pure bibliotherapy, or therapy by book, was recognised as an effective way to treat depression and anxiety, there was growing evidence that it wasn’t sufficient for many people. By 1997 the concept of what we have come to call ‘guided self-help’ was already in the literature. Supported or ‘guided’ self-help became the norm; patients were provided with self-help literature based on CBT principles, but they were coached to learn and use the material by practitioners who understood the theory and practice of the interventions. In the 2009 guidance on depression in adults (NGCG90), NICE recommended both ‘individual guided self-help based on the principles of cognitive behavioural therapy (CBT) and computerised cognitive behavioural therapy (cCBT)’, and this recognises that the self-help ‘literature’ could, in fact, be any health technology that provides accurate information, whether this is a book, a computer programme, or an audio file.

Guided self-help Low-intensity psychological interventions are sometimes called guided self-help (GSH). A core principle of this approach is that a patient is more likely to experience helpful change if the patient is educated to understand the difficulties the patient is experiencing, either depression or a specific type of anxiety. Contact with a practitioner is supposed to facilitate access

Low-intensity psychological interventions Chapter | 1  7



to educational material that will guide the patient to understand and manage difficulties the patient faces. Once the patient understands the problems and can see why making the suggested changes could be helpful, the low-intensity practitioner guides and coaches the patient to implement the evidence-based changes that are recommended for the specific problem description. Above all, self-help is about ‘a philosophy of patient empowerment’ (Foster, 2006), which fits nicely with CBT’s pragmatic philosophy and was a crucial factor recognised in the development of the manualised low-intensity interventions that we deliver in IAPT.

Self-help resources By the time that the IAPT programme was launched, several high-quality self-help manuals were available, most of which I have recommend to my patients and the practitioners who I supervised over the years: ●

●

●

Overcoming Depression (Gilbert, 1997), part of the comprehensive ‘overcoming’ series of self-help books, this is a book that I recommend to patients who enjoy reading and who like to understand the ins-and-outs of the ideas that we work with. Mind Over Mood (Greenberger and Padesky, 1995), a comprehensive self-help guide that presented cognitive techniques in an accessible way. A clinician’s guide (Padesky and Greenberger, 1995) was released alongside the self-help manual with ideas on how to apply the cognitive techniques to different problems and ideas for homework tasks. Overcoming Depression: A Five Areas Approach (Williams, 2001a) and Overcoming Anxiety (Williams, 2003): Chapters from these books were available as stand-alone self-help workbooks. My first two employers in my low-intensity career kept huge stockpiles of these chapters in floor-to-ceiling cabinets to hand out to patients, and I still distribute PDF copies to patients who like very thorough guides to the model and the interventions. Specifically for practitioners, resources like

●

●

●

The Mental Health Handbook (Powell, 2000) was designed specifically for guided self-help and contained worksheets and handouts of self-help information that a practitioner could photocopy or print to support the work that they were doing with a client. Self-Help Access in Routine Primary Care (SHARP) (2006) was developed to provide easy access to a good-quality self-help material in primary care settings. It is an online resource that was designed to be easy to navigate and print. I used SHARP frequently in my early PWP career, and it is still a helpful and well-rounded resource. Using CBT in General Practice: The 10 Minute Consultation (David, 2006) sat on the desks of a lot of GPs in the early 2010s. An essential resource in time-limited primary care appointments (GPs in England typically allow 10 min per consultation) that emphasises core CBT principles supported by motivational interviewing.

Two good short reads to get a glimpse into the development of the use of self-help material are Self-Help: Empowering Service Users or Aiding Cash Strapped Mental Health Services? and Use of Written Cognitive-Behavioural Therapy SelfHelp Materials to Treat Depression (Williams, 2001b). Texts like those that I have listed formed the foundation of our early understanding of the interventions that we offer and provided a way of explaining our approach to other professionals and accessible resources for our patients to use. Treatment manuals that provide education and suggest helpful changes are fundamental to how we practice low-intensity interventions in IAPT. This, of course, presents problems when a population is not literate or when written material is not readily available in the patient’s first language. We will come back to that in Chapter 3 on training and competency.

Low-intensity group work Another early manifestation of what we now call low-intensity therapies was effective psychosocial education programmes that delivered self-help information to groups of patients. These were different to the traditional ‘therapy groups’ offered by therapists from different modalities and did not invite analytical contributions from the facilitators, or self-exposure from participants, but created an atmosphere of shared learning. Kellett et al. (2007) emphasised that ‘psychoeducational group CBT’ was developed in response to the need for ‘prompt, safe and effective’ primary care psychological interventions. The 2007 study found comparable results from the education groups when compared with individual CBT and individual psychodynamic therapy. The most famous and measurably effective (Dolan et al., 2021) psychoeducation programme is Jim White’s didactic Stress Control course that was developed in Glasgow, Scotland (White et al., 1992). This course covers a comprehensive range of information about stress, depression, and anxiety and the CBT-based self-help techniques that can be used to

8  Care in high volume

­ anage those difficulties. Stress Control made use of outcome data from the start and is typically delivered in the IAPT m programme by two low-intensity facilitators who follow the script written by Jim White. Stress Control demonstrated a mass delivery system for self-help material and emphasises the educational aspect of low-intensity interventions.

Case study: The South Yorkshire Condition Management Programme The South Yorkshire Condition Management Programme (SYCMP) was part of the Pathways to Work model delivered by the Department for Work and Pensions, piloted in 2003. The aim of Pathways to Work was to ‘assist incapacity benefits claimants into, and towards, paid work’ (Becker et al., 2010). Within the package of services described as ‘Pathways’, condition management programmes (CMPs) were usually delivered by NHS providers, and they aimed to ‘help incapacity benefit recipients manage their health conditions more effectively and return to work’ (Kellett et al., 2011). The SYCMP was a multidisciplinary team of general and mental health nurses, occupational therapists, physiotherapists, assistant psychologists, support workers, and patient volunteers. The team was trained in a CBT-based self-help approach using Chris Williams’ 5 areas model self-help manuals (Williams, 2003), and they delivered psychosocial education groups based on this model over seven sessions with total practitioner contact time of 26 h per seven session course; this included a 1-hour assessment appointment, six group sessions of 4 h, and one follow-up appointment, where participants met individually ­ with a course facilitator to plan and set goals to be completed after the end of the programme. This will sound very familiar to anyone who has encountered a low-intensity psychoeducation course in an IAPT service. The SYCMP also provided shorter

courses for pain management, fatigue management, and insomnia. The psycho-education courses were delivered in several venues, including hotels, sport and leisure centres, and even the local city hall. Lunch and refreshments were provided at every weekly session, and participants had the option to take up a free leisure pass that gave them access to local sport facilities for 3 months after the end of the programme. The SYCMP was available to incapacity benefit claimants who had physical or mental health conditions that impacted on their ability to engage in work-related activity. Unlike IAPT, the mental health conditions that participants lived with were not limited to depression and anxiety disorders. The programme showed its best results (using a barrage of outcome measures pre- and post-treatment and at 3-month follow-up) for participants with mental, rather than physical, health conditions. A total of 50.5% of the participants of the programme showed significant improvement in psychological wellbeing, but only 16.3% had returned to work at the 3-month follow-up (Kellett et al., 2011). This programme demonstrated how adaptable low-intensity CBT informed interventions can be, both in terms of settings where it can be delivered and the patient groups that can benefit from the approach. It also demonstrated that CBT informed management of health conditions could potentially support patients to return to paid employment, which was to become a driving motivator of the IAPT programme.

Graduate Mental Health Workers The Graduate Mental Health Workers in primary care (GMHW) were a step towards addressing a significant lack of provision. The initial goal was to train 1000 Graduate Mental Health Workers in a post-graduate certificate by 2004 (Lucock and Frost, 2004). They were not intended to be psychological therapists but to be skilled practitioners who would deliver evidence-based psychological interventions; how a typical patient is expected to make this distinction is still a mystery. As well as for ‘client work’ skills that included core concepts of mental health work and CBT theory, the training included modules on multidisciplinary working to aid the GMHWs to integrate and work effectively in primary care teams and competencies in the use of supervision. True to the spirit of the barefoot therapist, the training also retained a flexible module that could be negotiated with the local service provider to adapt to local needs (Lucock and Frost, 2004). Graduate Mental Health Worker roles were pitched towards psychology graduates and appealed to people who had an interest in the therapeutic application of the psychological theory. The Graduate Mental Health Workers are the true precursors of the current low-intensity psychological practitioners who work under a variety of job titles in an increasing number of settings. What the GMHWs didn’t have was the context of the organisztional structure that has allowed Psychological Wellbeing Practitioners in IAPT to provide safe and effective interventions whilst developing a distinct professional identity. In the first years of the IAPT programme, starting in 2008, many of us joined teams that had absorbed the local ‘barefoot therapists’ (primary care mental health workers with a core profession and the post-qualifying certificate in mental health work), Graduate Mental Health Workers, and counselling services. In my local team, the primary care mental health workers and Graduate Mental Health Workers either secured places on high-intensity CBT training courses or were employed as Psychological Wellbeing Practitioners. Those practitioners who stayed within the low-intensity workforce were provided with some sort of ‘top up’ training to familiarise them with the IAPT model, but largely left to practice as they always had.



Low-intensity psychological interventions Chapter | 1  9

There was no national standardisation of that top up training. Some practitioners received a certificate and equivalence with the accredited certificate that the new PWPs achieved. Others were given a 2-day course on how the IAPT system worked. In 2018 the ‘IAPT Manual’ provided a very explicit guide for IAPT commissioners and specified training and qualifications standards for practitioners within the programme. In 2021 NHS England introduced mandatory registration for all low-intensity practitioners in the IAPT programme; registration (which has now become a requirement for employment) could only be completed by practitioners with an accredited qualification or an agreed equivalent. This created significant problems for some Graduate Mental Health Workers who were still in practice in IAPT whose top up training didn’t meet this standard, many of whom, understandably, resented the implication that they had been practising without adequate qualification for more than a decade. Counsellors, many of whom had held the fort in primary care mental health, often working alone and consistently in GP practices and small districts for decades, were offered IAPT roles as ‘Step 3’ practitioners. They were given one pay band above the newly qualified Psychological Wellbeing Practitioners, one pay band below the newly trained ‘high-intensity therapists’ who had completed a post-graduate diploma in manualised CBT interventions for depression and anxiety. In the teams that were lucky enough to have them the ‘old guard’ of the preexisting primary care mental health teams of whatever profession and training were the backbone and anchor for low-intensity cohorts like mine—a voice of experience, goodsense, and much-needed cynicism in the early years of IAPT’s hubris and self-satisfaction.

High volume An essential function of low-intensity roles has always been to provide capacity in the primary care mental health system to meet the high level of demand for effective psychological care. We are high-volume practitioners; we work for a short time with a lot of people. The IAPT implementation plan for low-intensity workers (Department of Health, 2008) didn’t make any bones about the high-volume nature of the work: ‘Low-intensity workers are expected to operate in a steppedcare, high-volume environment carrying as many as 45 active cases at any one time, with workers completing treatment of between 175 and 250 patients per year’ (p. 5). The second edition of the National Curriculum for the Education of Psychological Wellbeing Practitioners (Richards et al., 2011) repeated the same figures, in the same words (p. 9), but the specific numbers of the Low Intensity caseload were omitted from the 2015 Third Edition of the National Curriculum during the PWP training review (University College London, 2015). I will add that as a full-time qualified low-intensity therapist in 2011, my local team asked PWPs to see 8–10 patients per clinic day, and clinic days were 4 days per week for a full-time member of staff, with 1 day per week allowed for nonclinical contact activity. Seeing eight or more patients per clinic per day, some of whom were seen on a fortnightly, instead of weekly, basis, meant that I carried a caseload of around 60–70 active patients if I stayed on top of things. That number went up if I didn’t keep ahead of my caseload administration. For now, let’s acknowledge that this was a new concept in talking therapies where quality had always been prioritised above quantity. The boast of IAPT has always been that the programme will achieve patient recovery rates that are comparable with clinical trials. This new workforce was expected to deliver both high-volume work and an exceptionally, measurably, high standard of work. This idea wasn’t pulled out of thin air as with every element of low-intensity development, huge amounts of work had been carried out for years to test and trial the ideas before they were implemented on a national scale.

NICE The National Institute for Health and Care Excellence (NICE) was relatively new when IAPT burst onto the scene. Formed in 1999, NICE and its guidelines are foundational to the IAPT ethos. The stated purpose of IAPT services is to implement NICE-recommended interventions. When the phrase ‘evidence-based’ is thrown around in IAPT circles, it means ‘NICEapproved or recommended’. NICE, in the words on their own website (NICE Guidance, 2021), ‘use the best available evidence to develop recommendations that guide decisions in health, public health, and social care’. Part of my induction to the NHS included a talk on the process of developing NICE guidelines. It is a years-long process that involves a review of the available evidence base; consultation with stakeholders, including patient groups; and weighing up the costs and benefits of the available treatments to ensure that resources are used as equitably as possible, for the greatest overall good. By 2006 NICE had produced five sets of guidelines that outlined the identification and treatment of depression and anxiety disorders in adults. These described what treatments their review of the evidence base concluded were most effective;

10  Care in high volume

this included medication options and talking therapies; talking therapies included a range of CBT-based self-help options and a suggestion that there was some benefit to ‘case management’ of mild depression in primary care. Early responses to the 2003 Depression guidelines suggested that the new staff group of Graduate Mental Health Workers could fill this case management role (McMahon et al., 2007). By then, about 1000 Graduate Mental Health Workers were trained and in work, and that was never going to be enough. There was also the problem that the graduate/primary care mental health workers had a generous scope to their role. They were essentially ‘physician extenders’; there to pick up some of the burden of mental healthcare that GPs and other practice staff didn’t have the capacity or training to manage in primary care. They were not limited to working with depression and anxiety disorders, and they were not limited by the severity of the symptoms that a patient experienced. The Graduate Mental Health Workers could work in close collaboration with the GP practice team and local mental health services to provide a service to anyone whose difficulty fell under a ‘mental health’ problem description. The NICE guidelines called for something different, a more specific role that had the scope to implement evidencebased CBT-informed interventions for depression as well as some anxiety disorders. PTSD, social anxiety disorder, and OCD were initially excluded from treatment with low-intensity interventions. There were also recommendations that lowintensity staff should not offer treatment to patients with more severe symptoms. The relationship between NICE and IAPT is interesting. NICE guidelines gave the IAPT programme focus and boundaries. This moved low-intensity interventions in primary care in England away from a broad remit to work with ‘mental health’ conditions and narrowed us down to providing evidence-based psychological therapies for depression and anxiety disorders. The effect of this narrow focus has been problematic, with a recent paper declaring that IAPT is not sufficient to treat the complex presenting problems in primary care (Martin et al., 2021).

Stepped care The usual method of accessing CBT for clients is based on a traditional delivery system of outpatient appointments. Therapists work from offices and clinics in secondary care or primary care settings. Patients are usually allocated 45–60 min per session and receive therapy on a weekly basis for 6–12 sessions in total. Treatment is usually face-to-face, individual-based, and requires the client to engage in a collaborative therapeutic relationship with the therapist. In order to receive therapy, clients usually have to travel to the therapist’s office and to do so between the hours of 9.00 a.m. and 5.00 p.m. To gain access to the therapists’ waiting list in the first place, clients will have to consult either their GP or a secondary mental health care professional. From the MAPLE report (Lovell and Richards, 2000).

Stepped care is a way to organise access to psychological therapies that is based on the principle that patients should have access to the least burdensome intervention which has a reasonable chance of success. In this way, people are not overtreated with an intervention that is hard work when something straightforward and simple would help them to achieve their goals. Essentially, the ideal is that you get the least burdensome treatment for your problem that has got a reasonable chance of being successful. If that treatment doesn’t help you, then you should be ‘stepped up’ for a more intensive therapy. This process is facilitated by session-by-session outcome measures so that decision-making is informed by self-reported data. ‘Least burdensome’ means that the help that you get should cost as little as possible in terms of time, travel, effort, and money (for you and the care system), whilst still helping you.

Options One of the pioneers of this service model was David Richards, who identified two possible ways to design access to psychological care: Stepped care was one potential model, and stratified care was the other. In stepped care, you ask every patient to start with the ‘least burdensome’ available treatment. This will maximise the number of people who receive a low-intensity intervention, but there is a risk that low-intensity interventions will not be sufficient or helpful for the patient, and you have created a delay in them getting adequate care. Stratified care models rely more on the initial assessment to place the patient at the most effective level of care as quickly as possible (Richards et al., 2012). More recent research into stratified care utilises demographic data and patient profiling tools to indicate an appropriate level of care (Delgadillo et al., 2022).

Low-intensity psychological interventions Chapter | 1  11



From an evaluation of the Doncaster IAPT demonstration site At the first appointment, the case manager conducts a ­patient-centred assessment, including a risk assessment, and asks the patient to complete a battery of clinical outcome measures. The case manager then gives the patient written information appropriate to their problems, discusses treatment options, and arranges a next appointment, usually telephone-based. If any significant active risk of harm to the self or others is detected, the case manager will initiate the appropriate risk management protocol. At the first telephone follow-up contact, the case manager reviews the treatment options offered and initiates a low-intensity treatment CBT programme for anxiety or depression. Mostly, this uses the

written materials, although case managers also support patients in the same way should they wish to use computerised CBT. Subsequent contacts are generally on telephone and include sessional outcome measures so that case managers are able to receive online real-time feedback of patient progress as they are conducting all treatment sessions. The use of real-time clinical outcome measures enables rapid decision-­ making. Formal reviews of patient progress are conducted every 4  weeks. Depending on patient progress, decisionmaking may include advising the patient to remain in lowintensity treatment for another 4  weeks, to discharge from active treatment, to step up to high-intensity CBT, or to refer to alternative services requested or required by the patient (Richards and Suckling, 2008).

Base or apex In the most recent NICE interactive flowchart (accessed online in July 2021), which is based on the Guidelines for Developing Local Care Pathways for Common Mental Health Disorders (NICE, 2011), the recommendation is that psychological interventions in primary care should use a stepped care model of service delivery and should ● ●

● ●

provide the least intrusive, most effective intervention first, have clear and explicit criteria for the thresholds determining access to and movement between the different levels of the pathway, not use single criteria such as symptom severity to determine movement between steps, and monitor progress and outcomes to ensure the most effective interventions are delivered and the person moves to a higher step if needed.

These points might bring ideas to mind of what the patient pathway and practitioner experience would be like in that system. In large part, this ‘pragmatic’ guide to low-intensity therapies will explore the differences between what should be happening, what is happening, and what this means for low-intensity interventions as an approach. The stepped care model is often presented as a pyramid with Step 1 as the base and Step 4 as the apex, and this indicates that the majority of patients are seen at the earlier steps of the care model. The effect of this is to visually emphasise that low-intensity interventions are hierarchically below the other treatment options available in IAPT. The Guidelines for Developing Local Care Pathways for Common Mental Health Disorders (NICE, 2011) assumes that 60% of the people who suffer from depression or anxiety disorders will not access treatment, and that a further 20% will receive care at Step 1, never entering IAPT. Those guidelines then estimated that 45% of the remaining patients with common mental health disorders would receive care at Step 2, 30% at Step 3 and 25% at Step 4. I have not been able to identify exactly comparable data to demonstrate how the use of IAPT has matched this prediction. However, the percentages of the people who do access IAPT who complete treatment at each step is interesting and shows that 34% of the people who have more than one appointment in IAPT see a PWP only, that is, they receive care only at Step 2. Forty-two percent of patients who have more than one appointment in IAPT access care at both Step 2 and Step 3, with only 24% of patients recieving care only at Step 3. This means that around 76% of patients who have more than two appointments in IAPT benefit from low-intensity interventions as part of their treatment journey after assessment, and this compares to 66% of the people who accessed IAPT using a Step 3 intervention (either CBT or an evidence based counselling modality) as part of their course of treatment.

Who does what? Descriptions of Steps 1–4 of the stepped care model are listed in Table 1.3.

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TABLE 1.3  Descriptions of Steps 1–4 of the stepped care model detailing what care is provided at each step and what problems are likely to benefit from that level of care. Step 1

Primary care/GPs identify depression or anxiety disorder and provide self-help information and watchful waiting in case of natural recovery. Medication prescription and management if needed. Signposting or referral to IAPT if recovery is not achieved.

Initial onset of symptoms and sub-clinical symptoms of depression or anxiety

Step 2

Psychological Wellbeing Practitioners or other lowintensity psychological practitioners provide evidencebased guided self-help and other appropriate low-intensity interventions like sleep hygiene and signposting to social support

Mild to moderate symptoms of depression and anxiety or simple depression and anxiety if the patient declines Step 3 Should not be offered as a first-line treatment for social anxiety disorder Low risk of suicide or self-harm

Step 3

High-intensity therapists CBT Interpersonal therapy (IPT) Person-centred experiential counselling Eye movement desensitisation and reprocessing (EMDR) Couples counselling for depression

Moderate to severe symptoms of depression or anxiety NICE recommends this as the first-line psychological step for social anxiety disorder and post-traumatic stress disorder Low risk of suicide or self-harm

Step 4

Highly specialised psychology, psychotherapy, and counselling, secondary care mental health services

Severe, complex, recurrent, and severe depression and anxiety, and high risk of suicide or self-harm

Bringing it all together The ingredients for the low-intensity element of the IAPT programme were as follows: 1. A huge and unmet need for effective treatment of common mental health disorders in primary care. 2. A growing evidence base demonstrated that cognitive behavioural therapy–informed self-help interventions could be effective for those common mental health disorders. 3. A recognition that self-help is more effective when it is facilitated by a specifically trained practitioner. 4. The recognition that high-volume psychological work was feasible. 5. New models for providing access to psychological therapies in primary care became available. 6. The NICE review of the evidence base and the publication of guidance for depression and anxiety that specifically recommended a stepped care system that offered both high- and low-intensity psychological therapies. This very brief list, in fact, this whole chapter, does not do justice to the years of work by many people that went into the initiation of the IAPT programme, so I highly recommend that you dig into the literature for yourself and explore the discussions that I have not been able to include here. We are now at the end of the historical preamble; it was in this context that Lord Layard and Dr. David Clarke proposed their shared ideas.

Guiding principles Low-intensity interventions in England have become synonymous with simple manualised CBT-based interventions because of our adherence to NICE guidelines. However, low-intensity interventions are not practised exclusively in England, and there are further underlying core principles that should be considered if you are planning and supervising effective low-intensity provision. I write more about this in Chapters 3 and 11 on competency and professional identity; for now, this list is a starting point and is not intended to be exhaustive. 1. The patient is the agent of change, and the therapist facilitates and encourages change. We aim to build a sense that the patient can act on the world to change things (Lovell et al., 2008). 2. CBT competencies don’t describe the whole low-intensity approach. Good low-intensity practice also integrates behaviour change models and techniques (Pilling et  al., 2015). There are also promising developments of low-­intensity interventions based on other therapeutic modalities (Meadows and Kellett, 2017).

Low-intensity psychological interventions Chapter | 1  13



3. Co-production of services with equal involvement from patients and practitioners, and working in partnership with family and caregivers as well as patients (Taylor, 2003). 4. Integration with existing healthcare pathways and team-working with physical and mental healthcare practitioners (England and Helen, 2007). Low-intensity interventions work best and most safely when they are provided in collaboration with other types and intensity of care. 5. ‘Human support increases the probability of success’ for low-intensity interventions (Kuroda et al., 2021); the balance of interpersonal and engagement competencies with competencies in specific low-intensity interventions needs to be considered during recruitment and training.

Evidence, economics, and serendipity In 2006 Lord Layard published a report that concluded that lots of people in England were depressed and anxious, and people being depressed and anxious cost the British economy more than £70 billion every year. The idea of training enough clinical psychologists and psychotherapists to offer talking treatment to a quarter of the population was preposterous. ‘We need a cheap way to get them better quickly and keep them working’ (that’s a paraphrase) he cried, and thus, the Psychological Wellbeing Practitioner (PWP) was born. It wasn’t quite that straightforward, of course, but that’s how it feels in light of following events. Professor David Clark is the psychologist most associated with the creation of Improving Access to Psychological Therapies (IAPT). Professor Clark had produced manualised cognitive-behavioural interventions for anxiety disorders that produced significant and reliable reduction in symptoms in clinical trials. He wanted to disseminate his treatments to as many people as possible and worked with the department of health and government ministers to secure funding for the IAPT programme, of which he is still the national clinical advisor. Professor Clark at the BABCP annual conference in Bath in 2019 told a story about a chance encounter with Lord Layard in 2004 in the tea queue at the British Academy. Lord Layard was thinking about how to provide good enough psychological interventions that would relieve the misery that his report described, and bring those lost billions back into the economy. Professor Clark wanted to disseminate effective, evidence-based psychological interventions. They were chatting, and from that encounter, a multimillion pound investment of public funds resulted, which touched the lives of millions of people.

A patient journey whilst systems changed. Mark is a 60-year-old architect who had his first episode of severe depression at the age of 40. He describes that he realised that he was very unwell when he ‘shut down’ and was unable to cope with activities at work or at home. His GP referred him to a community mental health team, where he had some appointments with a psychiatrist for medication management and support from a mental health nurse. At that time the team did not specify that they were using a cognitive-behavioural approach, but the psychiatrist noted ‘we’ve got to keep you swimming’, and the mental health nurse taught him a cognitive restructuring technique to address the negative thoughts that maintained his depression. Nearly 20  years later, he still remembers some of the imagery used by that nurse to explain the maintenance cycle of depression, and it is identical to what I have used in my own work. Ten years later, at age 50, he became unwell again and was referred for a course of CBT in a secondary care team. He found this helpful and was able to stay well for another decade when increased responsibility at work caused an episode of stress that left him doubting his ability to make safe decisions at work, and fearful of another episode of severe depression. He self-referred to IAPT and was advised to en-

gage with guided self-help with a Psychological Wellbeing Practitioner (PWP) after his assessment. During treatment, the PWP encouraged him that he had done the right thing in reaching out for further support as soon as he noticed that he was unwell again. They agreed that Mark already had a lot of the information that he needed to manage this episode of depression, but the PWP would be able to provide some up-to-date resources and support to implement the changes that would help him feel well again. The PWP also noticed that Mark’s language was self-blaming and demanding, so they encouraged him to take on a more self-compassionate attitude that would enable him to get the most from the approach. Mark described the reflections offered by the PWP as insightful and motivating. The PWP shared several self-help resources by email for Mark to read at his own pace. In five 30-min-long sessions, they went through a cognitive restructuring exercise (Richards and Whyte, 2011), planned and implemented strategies for managing stress at work, discussed assertive communication techniques to help Mark manage a difficult family dynamic, and encouraged Mark to resume swimming and contact with friends. Mark improved quickly, and he declined a sixth appointment, saying that he had got what he needed. Mark was discharged from IAPT as ‘recovered’ on self-reported measures.

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Training and competencies Training courses for low-intensity practitioners who will work in the IAPT programme are accredited by the British Psychological Society. In July 2022 there are 33 accredited training programmes for low-intensity psychological interventions in England (British Psychological Society, 2021) that offer postgraduate and graduate routes to qualification in 17 institutions, as well as a growing number of apprenticeship programmes. The curriculum includes specific and general clinical skills competencies, assessment protocols and skills, and a grounding in the essential theory and practice of the low-intensity treatment interventions that are recommended by NICE for Step 2 of the stepped care model. Modules on equality, diversity, inclusion, and adaptation are just as essential to good practice, and the topic of supervision is crucial. Typically, trainees will work for 4 days of the week in their local IAPT team and attend the training programme for 1 day a week, although the training timetable varies by training provider. Assessment for the training course can include live assessed skills practice, submission of recordings of clinical practice, academic essays, reflective writing, exams, and a practice-based portfolio that provides evidence of clinical skills competence. When I trained in 2010, we measured ourselves against the competencies described in the CBT competency “Bible” The Competences Required to Deliver Effective Cognitive and Behavioural Therapy for People with Depression and with Anxiety Disorders (Roth and Piling, 2007). The drawback of this was that those competencies described effective CBT practice and low-intensity therapists are not CBT therapists. In these modern times, we have got specific and fit-for-use tools to measure low-intensity competency that are closely aligned to the evidence base for the role and easy to use in typical practice (Kellett et al., 2021).

IAPT into action The IAPT initiative was a blend of the economic argument and the best emerging guidelines following a review of research studies into the effectiveness of talking therapy and other treatments for depression. ‘We start from a very bad situation. Millions of people who suffer from depression and chronic anxiety are left without help, even though therapies exist, which could lift at least half out of their misery. Shame keeps their misery a secret. And the cost to the exchequer exceeds the cost of cure’ (Layard, 2006).

Based on this argument, Pilot sites in Newham and Doncaster (Clark et al., 2009) received about £1.5 million in 2006 to expand their provision of psychological therapies based on the NICE guidelines and a stepped care model. The practitioners at those sites did outstanding work, and the pilots were considered a success. In 2007 the UK government announced an investment of £173 million to roll out the IAPT initiative across England (Department of Health Mental Health Division, 2008). The plan was to train upward of 3000 new therapists in CBT-based interventions because there was a shortage of people with any CBT training, and IAPT got up and running in 2008.

Give me the right lever When you read the documents that were published on this topic around 2006, the tone is deeply compassionate. The scope of the problem had been understood for years, but the economic argument for improved access to psychological therapies had to be made; you can’t invest millions of pounds of public funds for no return (apparently). The financial implications aside, there was a growing recognition that a huge proportion of the population in England was suffering from depression and anxiety, with one in three families affected by one or both conditions, and those people were not getting enough help. There is a frustration in the Depression Report that very simple interventions were available that could be provided at little cost, with huge benefits, but these were not readily available to the public. The motivation behind the IAPT programme was to respond to this information practically, and to relieve suffering.

What’s in a name? A quick internet search reveals the confusion amongst psychology graduate job applicants in 2009, which was a year after the implementation of the IAPT programme and after low-intensity therapies were more widely available and formal



Low-intensity psychological interventions Chapter | 1  15

training routes had been commissioned. There were competing roles in the field of applied psychology that all seemed to offer the same experience and opportunities: Graduate Mental Health Worker, assistant psychologist, associate mental health worker, primary care mental health worker, and IAPT high- and low-intensity positions. These are just the job titles that were mentioned in one comment in an online forum for aspiring clinical psychologists (anon, 2009). In 2021 this confusion of terminology continued (Shafran et al., 2021). This range of employment options demonstrates that low-intensity therapies had developed as a key component within the provision of psychological therapies in primary care mental health services. For graduates and practitioners who wanted to support people with mental health conditions in primary care, or who were interested in the therapeutic application of psychological theory, low-intensity therapies offer exciting opportunities. That’s all great, and what isn’t so brilliant is the utter confusion caused by the sliding nature of the job titles given to low-intensity practitioners. In this chapter alone, we’ve travelled from Mark’s barefoot therapists, to Graduate Mental Health Workers, to ‘case manager’ in the Doncaster pilot site; we’re about to land on Psychological Wellbeing Practitioners within the national IAPT programme. You’d think that we could catch our breath there, but no, it goes on. Anecdotally and in the literature about IAPT, I’ve heard and read references to ‘junior mental health workers’ (Richards et al., 2016), low-intensity therapists/practitioners/workers, and ‘IAPT workers’. In the devolved nations of the United Kingdom, there are Psychological Wellbeing Practitioners who do jobs that do not resemble the work of the low-intensity practitioners in the IAPT programme. All of this is confusing from the outside, and rather maddening from the inside. We’re about to look at how the IAPT low-intensity workforce have had a pretty rough go of it over the last 15 years or so. The confusion of language indicates a confusion of perception about who we are and what we do. That lack of understanding, in turn, translates into a lack of respect and status that directly impacts our conditions of work and the wellbeing of this workforce. The confusion of language contributes to intraprofessional difficulties. In the published literature and on social media, we see talking therapists of all professions confusing and conflating different professional titles. If our colleagues in the professions can’t be expected to keep the terms and jobs clear, it’s so much more difficult for the people who use our services. Most of the time if a patient says that they have had ‘CBT’, there’s a good chance that they accessed a low-intensity intervention and not CBT. Likewise ‘counselling’ is used as a catch-all term for ‘talking therapy’ by both patients and many of our medical colleagues.

Informed consent When we start to work with someone, best practice is to give your full name and job title, and a brief explanation about your role and what you are qualified to offer. This is important and shouldn’t be skipped. Before someone can give informed consent to treatment, they have to know what the treatment is and that the person who is providing it is qualified to do so. I’ll often tell my students that it’s our duty to give our patient enough information to make a complaint about us if they need to! Put yourself in the place of a person who is unwell with depression or anxiety; you have been to the doctor who has told you that you can book an appointment with a ‘counsellor’ (because many GPs are still not familiar with the different roles and job titles in IAPT and see all IAPT staff as a version of the ‘practice counsellors’ from the land before IAPT), and you arrive at the appointment, seeking help, nervous, and maybe hopeful. The person then spends the first 2 min of the appointment talking to you in jargon. How much are you going to remember? How important does it feel? Agreeing on workable job titles and disseminating information about what those titles mean so that they are as embedded into our cultural awareness as much as ‘counselling’ is, would be very helpful. There’s more about job titles and how this links to our professional status in Chapter 11.

Professional terms To avoid further confusion, Table 1.4. explains what the authors mean when we use job titles and descriptions of therapeutic approaches in the rest of the book. Note that this is our interpretation of these words, and some of them have no agreed universal usage. I have drawn on the information that is available on the excellent Psychological Professions Network Career map (Psychological Professions Network, 2021).

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TABLE 1.4  The psychological professionals who commonly work in the IAPT remit in the United Kingdom. Low-intensity interventions

Brief, evidence-based psychological interventions following the principles outlined here, and local evidence-based competency criteria

Therapist

A practitioner whose work provides healing and has a good effect on the body and mind and contributes to a sense of wellbeing

Psychological Wellbeing Practitioner (PWP)

The job title given to low-intensity practitioners who work in the English IAPT programme. This role requires an accredited qualification in low-intensity psychological interventions. PWP is also used as a job title for other roles in various nations and healthcare settings that may specify a different scope to the role and may not have the same training requirements

Counsellor

A broad ranging term that generally includes therapists who work predominantly through the ‘common factor skills’, relying on the quality of the therapeutic relationship to bring about change for the client. Counselling qualifications vary in length, often up to several years, and can be obtained at varying academic levels and may draw on a number of different therapeutic models

Psychotherapist

A broad ranging job title that describes a range of therapists working from varied theoretical models. The accredited training is usually at the masters level over at least 4 years part-time, combined with clinical practice under supervision and, in many cases, whilst undergoing personal therapy

CBT therapist

Qualified to at least post-graduate diploma level by accredited courses in either highintensity psychological interventions (IAPT) or CBT. CBT therapists employ some of the same ‘Common factor skills’ in interpersonal relationship and patient engagement as counsellors, but the focus of the work is to encourage patient self-efficacy through an empirical approach to the presenting difficulty

Clinical/counselling psychologist

Applied psychologists are qualified to the doctoral level and are commonly trained in multiple therapeutic approaches to psychological distress, across the lifespan

Outcome measures Low-intensity interventions are by no means a cure-all. One paper found that more than 60% of the people in the study cohort had been ‘stepped’ or referred upward to high-intensity interventions after an assessment with a low-intensity therapist (Hepgul et al., 2016). This contrasts with the report from the Doncaster pilot site, during which ‘less than 10 percent of patients stepped up from low- to high-intensity treatment’ (Richards and Suckling, 2008). IAPT prides itself on transparency in data and outcome reporting, and IAPT outcome data are freely available online (NHS Digital, 2021), but what is recorded is open to interpretation. The remit of this book is to add a report of qualitative experience to the quantitative data that are publicly available and to offer the lens of experience on the front line that is so far largely missing from the IAPT narrative. When you compare the published research and aims of the programme with the day-to-day reality of doing the work, the result is a sense that the literature is both patronising and naive. As we go on, it’s important to remember that the role of Psychological Wellbeing Practitioner was designed with two things in mind: cost-saving and the implementation of NICE guidelines. The lived outcome of my historical preamble is that we see as many people as possible at as little financial cost as possible, and deliver closely prescribed pieces of work under never-ending scrutiny. It’s also helpful to remember that low-intensity interventions were never supposed to be offered instead of mental healthcare services, we were an addition to provide support for a group in the population who had not had easy and timely access to effective care before.

High volume and low intensity IAPT is a revolution in psychological care and in the industry of talking therapies. It took a while but they figured out that you don’t need a clinical doctorate or 4 years or more of psychotherapy training to identify common mental health disorders and talk someone through the ideas that might help them to get better. If you had a workforce who trained for 1 year, instead of 3 to 10 years, obviously you wouldn’t have to pay them as much. They could be supervised by better qualified and more experienced people (you’d have less of those because they cost more), and it would be fine. Because this army of new and cheaper workers would only see people with mild to moderate symptoms their work would be easy, so they could

Low-intensity psychological interventions Chapter | 1  17



do more of it, and they could see lots of easy-to-treat people. From this we get the phrase that is supposed to sum up the work of low-intensity practitioners: high volume, low intensity. These four words are repeated so frequently that it feels like an attempt at brainwashing.

Outcomes vs experience The public narrative around IAPT has been one of success. So many practitioners trained, so many people seen, and so many waiting time and recovery targets achieved. Those of us on the inside, listening to data managers talk about ‘cleansing’ the reports, view that narrative with a squint. Surveys like the 2019 IAPT survey carried out by Dr. Elizabeth Cotton of Surviving Work have also received publicity. Of 650 respondents, 41% ‘had been asked to manipulate performance data and 70% had experienced burnout as a result of working in the service’ (Cotton, 2019). For context, the Health Education England 2021 IAPT workforce Census records 8191 patient-facing staff in IAPT in 2019, so results from the survey may not be representative of the entire workforce. If you look at comments on the official information pages online, there are comments from desperate people who talk about waiting lists, repeated attempts to access therapy without success, and an absence of any other option. One Redditor described their experience of IAPT in unflattering terms, and this was typical of the responses to the programme that I could find on message boards online ‘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). I talk more about the styles of low-intensity practice that can develop after qualification in Chapter 3. This perception needs to be balanced with the reminder that hundreds of thousands of people who have accessed IAPT report significant reduction in their distressing symptoms, and every IAPT worker who I have met has received thanks and affirmation from patients who found the service helpful. The argument that the cost of treatment is worth the money preserved in the economy by reducing illness, and access to healthcare services has never quieted. Fantastic things have happened because of the IAPT programme, and this book doesn’t intend to disregard the genuine success of the programme. We all know that nothing is perfect, but IAPT is so intent on presenting itself as a success that it isn’t able to learn from its own mistakes or accept outside criticism. This leads to a brittle defensiveness that doesn’t help anyone and is sometimes actively harmful.

Predictable problems Some problems were predictable. The British Psychological Society—the organisation that accredits the training courses for low-intensity psychological interventions—ran a series of opinion pieces in 2009 in their magazine ‘The Psychologist’. The introductory article was titled The Challenge of the Layard Initiative (Marzillier and Hall, 2009). This article didn’t pull its punches; the authors described it as simplistic to apply the medical model of diagnosis and treatment to psychological distress when the strict diagnostic criteria that are prescribed in clinical trials can’t apply in day-to-day clinical practice. They highlighted gaps in the evidence base that had informed the NICE guidelines and alerted readers to the risk of misdiagnosing normal, responsive emotions as depression of anxiety. They pointed out that simple, manualised interventions weren’t going to cure a disease, rather just alleviate distressing symptoms. The article goes on to highlight likely problems with the programme and reads as eerily precognitive from a 2020s perspective.

Into training Of the two authors of this book, I’m the low-intensity enthusiast mostly because it’s done me a lot of personal good and I’ve witnessed it help literally thousands of people. In 2007 I was recovering from a bad relapse of a health condition, and I was unemployed and receiving state benefits. The Jobcenter sent me to the South Yorkshire Condition Management Programme (SYCMP). The CMP was an exciting multidisciplinary NHS project that delivered low-intensity CBT interventions to people who were on work-related benefits. After completing the programme as a ‘customer’, I went on to volunteer with the team and later became a senior support worker with them whilst I

completed my undergraduate degree with the Open University. In 2009 we became aware of a new team operating in the city: IAPT. The IAPT programme was doing exciting things, sharing the same information as us, but they had a bigger team and closer relationships with the general medical practitioners (GPs) in primary care. The IAPT managers visited CMP team meetings, and my own manager beamed when he heard about the work that the IAPT programme was doing and how well it would complement our work and help the people who we saw. That was the first time I heard about P ­ sychological Wellbeing Practitioners (PWPs), who were working one to one with people in GP surgeries to help them with depression and anxiety.

18  Care in high volume

In 2010 I secured a training place with IAPT, I was going to become a PWP. This was a logical next step in my working life and exciting news that was soured the next day by the announcement that the SYCMP had lost its funding and wouldn’t continue. IAPT has continued to grow for the last decade; alongside that growth, low-intensity psychological interventions are now available in children and young people’s services, physical health condition care pathways, education settings, prisons, and community mental health teams, and may be about to branch

into relationship and sexual services, and there are rumours of developments in eating disorder services. Where IAPT goes, other services seem to shrink; the health and social care budget is a limited resource. So, is it worth it? Should there be this level of investment in low-intensity interventions? I’m not qualified to answer those questions, but I do want low-intensity psychological interventions to continue to emerge as a distinct therapeutic modality, find its feet, and be available to the people who, like me, could receive life-changing benefits from it.

Stability It’s only been in the last couple of years that access to increasing data has allowed people within and outside IAPT to raise more robust criticism. As well as the IAPT survey already mentioned Liz Kell and Clare Baguley of the North West Psychological Professions Network produced a report on the retention of low-intensity therapists (Kell and Baguley, 2018), and one table in the report struck me particularly: nearly 40% of PWPs left the role because they felt unhappy in the job or burnt out. In the corresponding column, stakeholders reported a perception that only 8% of PWPs were unhappy in the job. We have incorporated comments that were gathered in James’ substantial survey on low-intensity practitioner burnout and retention in Chapter 7. Retention of practitioners in low-intensity roles is the biggest challenge that faces the development of this profession and the continuation of the IAPT programme. There is a growing sense amongst the low-intensity workforce that it’s time to find our own voice and advocate for ourselves. PWPs can seem like the neglected child of IAPT, exploited, disposable, and often undervalued but incredibly resourceful and consistently successful in the work that they do.

Typical trainees In October 2010 10 trainee Psychological Wellbeing Practitioners met for the first time in a rented business suite in the city centre of a big city in the north of England. We had been recruited in a large Improving Access to Psychological Therapies (IAPT) service. Nine of us were women, and only four of us were older than 25 years; nine of us were white British. One of us was from a workingclass background, and the rest of us were middle class. Our backgrounds ranged from counselling and housing support to mental health support workers and NHS commissioners. I was 27, a married mother of one, and I felt old compared with the other six under-30s in the group. Those six

young women were all psychology graduates, immaculately groomed, keen, and serious. The managers of the service began the induction with a history of IAPT and the context of our new role. They described (with a graph drawn on the whiteboard) how our confidence in our skills and abilities would plummet when our training began (we didn’t believe them) and promised that we would recover and feel able and confident to do the job in a few months (they were right about that). When they described that our work could be minutely measured and tracked, and our recovery and engagement outcomes compared, seven of us sat forward, excited to prove that we were the best. That eager attitude didn’t survive the training year.

Really high volume, really not low intensity High-volume, low-intensity psychological therapies can work, depending on how high you make the volume and how carefully you manage the intensity. Grab any PWP who’s working for a provider on an NHS contract, and most of them will tell you emphatically and at length that their caseload is indeed high volume. Low intensity though? That’s not the norm. At the peak, when I was working full time as a qualified PWP doing 4 days of clinical work a week, my personal caseload exceeded 80 patients most of the time. I reviewed the report from that period recently and discovered that 56% of those people came to me with moderate-severe to severe symptoms of depression and anxiety at their first appointment. I worked out that people who started work with me at Step 2 with severe symptoms of depression only had a 15% chance of recovery at discharge, compared with an 85% chance of recovery for people who had mild - moderate symptoms at assessment. Technically the people with more severe scores should have been offered Step 3 work immediately, but pressure was on to try low-intensity work with everyone because Step 3 waiting lists were up to a year. Once you’ve spoken to someone and they have described their difficulty, you’ve listened with genuine empathy from the position of a helping role with an NHS lanyard hanging around your neck, it’s very difficult to say ‘I can’t help you, you need to wait a year for another assessment, there is nothing I can do’, especially when you know that there is a 15% chance that what you can offer could be helpful.



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Ideally low-intensity practitioners would not be put into that position in the first place, but realistically that is how most IAPT services structure their referral routes. What always emerges is that the high-volume caseloads that low-intensity therapists in IAPT are responsible for would never be described as ‘low intensity’ by anyone who speaks English as a first language. The balance got lost very quickly, if it ever existed as more than a soundbite. When I joined IAPT as a trainee PWP in 2010, I shadowed my supervisor for a day as part of my induction (shadowing is when you sit in an appointment and watch the practitioner do their work in a live setting) and by the end of the morning I felt numb, just from listening. How she maintained her calm and patience whilst nine people came through her door and I watched her manage her appointments and type her notes, asking questions and making naive observations on her work, is still a mystery. The content of the appointments was eye-opening, not the simple depression and anxiety that I had been led to expect. The presenting problems ranged from self-harm, to bereavement, to substance misuse. This leads us to one of the biggest problems with the glib high-volume, low-intensity description. That is that it ignores the fact that low-intensity interventions often boil down to sitting two people in a room together. James writes about the relationship dynamic and interpersonal competencies in Chapters 8 and 9. The interpersonal element of lowintensity work is ignored in the design of the typical PWP working week. In the PWP workforce, you’ve got a few thousand people who you’ve trained quite brutally to care about, empathise with and feel responsible for their patients. We also train PWPs in a structured and efficient assessment protocol that elicits the maximum amount of information in the minimum amount of time. So, for example, the patient who keeps going to their GP with persistent headaches and insomnia and got fobbed off to an IAPT appointment because the GP was at their wits end suddenly, after a nice young woman sits and asks him some open questions, has PTSD. That practitioner is potentially left to manage nine other appointments of equal complexity in that same day whilst carrying the details of whatever that traumatic incident was. That happens a lot, and it’s a problem.

Low-intensity supervision Supervision would usually be the mechanism that keeps a therapist safe whilst they work. It’s got a triple function: accountability to ensure patient safety, to continue skills gain and learning after formal training finishes, and to protect the wellbeing of the therapist. Supervision for PWPs was designed on the assumption that we would be working with ‘low-intensity’ cases, and the cost of our work on our mental and emotional health would be low. The fact that this isn’t the case and the majority of PWPs has experienced work-related stress, depression, or burnout has never been acknowledged or addressed at a system level. Our lack of care for PWPs risks a knock on the effect to patient care; someone who is experiencing vicarious traumatisation and compassion fatigue struggles to offer empathy, and clinical practice becomes defensive. We offer Chapters 7 and 10 on wellbeing and supervision, respectively, that explore these issues in more detail.

Social context Over the last few years there are a growing number of people in the United Kingdom whose lives are less predictable than they used to be (Alston, 2018). A psychological therapy service can support someone to make internal changes—to learn a way to understand their experience, manage how they think about things, make informed choices about what they do, and process strong emotion. What we can’t do is control or affect the circumstances of someone’s life, and people are increasingly in circumstances that are genuinely overwhelming, that they are powerless to control. We rely on other organisations to help with that: social activities, finances, physical healthcare, immigration, housing, carers and caring needs, cooking lessons, support with exercise, and how safe someone feels when they leave their house. All of these things are more difficult to manage than they used to be. At publishing, after years of government-imposed austerity and the economic crisis precipitated by the COVID pandemic and other factors, provision is changing fast and all of the social supports and resources that we took for granted in 2008–10 are fading away. James writes about working in this challenging social context in Chapter 4.

Expand or exchange? IAPT replaced existing counselling and therapy services with the new workforce. In some regions, IAPT has got bigger whilst not just counselling but mental health services have lost funding and had to reduce what they can offer significantly. It’s reasonable for people who use and refer to services to think that a replacement will be at least as good as what was there before. Add to that the fact that most GPs and other healthcare professionals don’t see much difference between a

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multidisciplinary mental health team and a psychological therapies service. (OK that’s probably unfair but that’s how it feels on most days). And they definitely don’t understand the difference between a psychotherapist with 6 years of training and 20 years of experience and a PWP who graduated with a 2:1 in psychology 2 years ago, did a support worker job for a year, and is now seeing their patients for IAPT assessments at the start of their PWP training. If I had a pound for every time someone has called me a counsellor, well, I’d be able to afford to train to be a counsellor. Throw that together with how stepped care is often put into practice; that is, you make entry into services go through one point, often without any kind of screening for suitability, so that the first person any new patient to the team meets is the most junior, least qualified person who has about half as much time to think as anyone else (that’s the PWP). You also make sure that services that operate any kind of screening system are penalised, thanks to the IAPT targets (targets are detailed in Chapter 10), and you end up with a significant clash between what commissioners, referrers’ and patients’ expectations, and what is provided.

Inside the low-intensity clinic room What’s it like to be a Psychological Wellbeing Practitioner (PWP) in IAPT? Here’s how an appointment can sometimes go NB: this is fiction, but the elements are typical enough to use as a realistic example. The PWP and patient (Pt) are sitting in a clinical room in a community healthcare clinic. The floor is laminate, the walls are white, there’s an examination couch and curtain in the corner of the small room, cupboards and draws full of medical equipment, bars across the window, and a vague, funny smell in the air. They are sat catty-cornered at the desk with the PWP in the desk chair and Pt on a plastic chair pulled up to the corner. It’s the third time they’ve met so they’re getting used to each other. The PWP is a young white woman dressed in smart casual, and the Pt is a 21-year-old man in T-shirt and jeans, there are holes in his trainers and a faint smell of body odour. In previous appointments, the Pt has scored high on the depression questionnaire and is describing having trouble motivating himself to look for work. He’s constantly restless during the session. PWP: Hiya, thanks for coming today, how’s everything going this week? Pt: So much has happened this week, just, so much. I need to tell you about my mum… PWP (sympathetically): It sounds like you’ve had a lot going on. So before we get started shall we…. Pt: You know I told you about mum? PWP: I remember you mentioned her last week and I know things have been difficult. I’d like to think about a plan for the session today…. Pt: Difficult is a major understatement. You know she left 5  years ago and I’ve been with dad, that bastard, well she’s come back and dad’s got really upset. PWP (genuinely sympathetic): Wow, it really has been a lot this week. Did you manage to do your questionnaires at all? I’d like to check how they are looking and then see how you got on with those activities that we planned last week. Pt: Oh yeah, but I forgot them on the kitchen table. PWP: Oh that’s a shame, so we’ll need to take a few minutes to fill those in today. Whilst you do them, maybe I could look at your diary? Pt: I didn’t do the diary, I couldn’t remember how to fill it in.

PWP: OK, well we’ve got 30 min maximum today so shall we have a think about what we want to cover? I know you’ve had a lot going on at home and that’s been more than usual this week; we were looking at how you could set up some routines to help your mood to improve. We were going to look at how that’s going, check your diary and see what had worked and if there was anything I can do to help with planning next week. I can see you’re really unsettled by your mum coming back but you might remember what I said about what I can help with? If we start talking about how you feel about your mum we might end up opening things up that I can’t help you with. Pt: Yeah, mum coming back is a big deal. PWP: So we need to think about what we’re going to do. Do you remember when I showed you the ABC? Pt: No. PWP: that was that diagram we filled in that showed how your body, behaviour and thinking can all affect each other. Pt Oh yeah…. PWP: and I explained that the work that I do is based on that. We did say that if you need to talk about things in the family and the big emotions that go with that, then you’d maybe need to see a counsellor instead of me. Pt: I thought you were my counsellor? Anyway, I can’t get my diary back. Dad got so cross this week, he got drunk last night and came up to my room yelling at me. We got into it and had a fight and he kicked me out. I might go to the police. PWP: You got into it with your dad? What kind of fighting do you mean? Pt: He punched the back of my head so we got into it. Honestly, do you think I should go to the police? PWP (putting her pen down): So have you got somewhere safe to stay now? Pt: I’m with my girlfriend, her mum and dad don’t mind if I stop over for a bit. I can’t go back to dad, he’s a right bastard. PWP: Do you feel like you need any help with sorting it all out? Pt: Yeah, maybe. PWP: OK, let me get you some numbers for SHELTER. If you decide to talk to the police do you know how to do that? It’s important that you feel safe…

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Psychological safety Although there is no evidence-based cap on low-intensity intervention session numbers, just the boundaries imposed by commissioning arrangements, the protocols for low-intensity interventions usually take 3–6 weeks to go through. The person who is learning about the interventions needs to feel safe and calm enough to learn and have time and space to practice the ideas. Someone who’s behaviour and circumstances are not stable and predictable is sometimes called ‘chaotic’ in the verbal shorthand that we use around the office. People in chaotic circumstances, like the Pt, are going to struggle to get the most out of low-intensity work. Sometimes we have to say this isn’t the right time and signpost people to the services that can help with whatever is happening and say ‘come back when things have settled down’. Which makes us worry that we’re giving up on someone (even though we know that we have done everything we can, and usually a bit more), and the patient might feel like therapy is useless because just when they needed someone to talk to the most, they were told that they couldn’t have more appointments. So what’s this got to do with our high-volume, low-intensity mantra? You remember the deal—you see lots of people to do easy, straightforward work, and that’s OK because each piece of work doesn’t take too much out of you. Now think about that conversation above representing the thin end of the complexity wedge. Think about meeting 8–10 people a day with similar circumstances and distress, think about caring what happens to all of them, think about having to assess and manage their risk of harm to themselves and others, and the risk of harm from others, and think of everything that could help them whilst being trapped between the rigid IAPT system on your side and a disintegrating system on the outside. Then think about how well the phrase ‘low intensity’ fits.

Training outcomes Of those nine bright young things that I started training with, two of us still work at low intensity, and we’ve both had a couple of episodes of extended sickness absence due to work-related stress and depression. One went back to their old job before the training course finished, two went on to CBT training, and five are now clinical psychologists. The seven people who left our team did so within 3 years of training, and all struggled with work-related stress before they left. The imbalance between the demands of the role and the reality of delivering it mean that for most people this is a job with a limited shelf life. In the years between my cohort and today, there have been waves of trainees, representing a vast investment of public funds in their training and employment. Most of those trainees have left the profession. Three years is the average time spent at low intensity. When you think about the cost of training and supporting a PWP, this calls into question the money-saving rationale on which IAPT was founded, never mind the cost in additional suffering that the system creates.

Gaps in guidelines In June 2022 a long-overdue review of the evidence for the treatment of depression was concluded, and the NICE guidelines for depression were updated. That was a hair-raising and aggravating process from the perspective of anyone involved in low-intensity psychological interventions. In the draft guidance that was released for comment from stakeholders before final publication, there wasn’t a single line that acknowledged the current reality of low-intensity practice, despite thousands of staff trained, multiple manuals and guides in print, and millions of GBP spent in England. There have also been other, independent developments around the world. NICE draft guidelines reduce our model and method to ‘self-help with support’. That might describe one of the precursor steps to this modality, but it certainly doesn’t capture where we are now, after 14 years of mass implementation and learning from practice. The published version of the guideline recommends ‘Guided Self Help’ as the first-line treatment for less severe depression in the psychosocial treatment pathway (as opposed to pharmacological treatment), but what it describes as ‘Guided Self Help’ is not what you will find described in this book. When I examined the draft guidance as part of a group that was responding to the consultation process, our conclusion was that a lack of good-quality research into low-intensity psychological interventions had contributed to the discrepancy between practice and what is available in the literature search. I can say ‘but that’s not what we do’, and the reply is ‘this is the conclusion that they have drawn from the best available published evidence’. We were also startled to see that the IAPT outcomes data—probably the biggest pragmatic record of psychological treatment and outcomes in the world—had not informed the draft guidelines. Given that the low-intensity psychological practitioner professional group emerged in response to NICE guidelines, this has been a frustrating, sometimes shocking process to engage with.

What now? At a regional senior PWP meeting in 2019, the Chair played a video by Professor Michael West from the NHS leadership academy (West, 2017) that described the human cost of providing care in the NHS. The risk of depression and anxiety

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disorders is 50% higher amongst people who work in the NHS than in the general population of England and that percentage goes up if you work in a service that provides mental healthcare. The problems in IAPT aren’t exclusive to IAPT, but they are a demonstration of difficulties that are faced by staff across the spectrum of NHS services. Amongst all of that though, some exciting things happen. Thousands of people go to IAPT services every month, and all of them report symptoms of depression and anxiety; a good proportion of them feel at least a bit better at the end of their time with IAPT. Claims that 50% of people who come to IAPT fully recover are still under discussion (James addresses this in Chapter 2), but we wouldn’t keep doing this work if we didn’t think that it offers real benefits to the people who we’ve seen. Low-intensity interventions are a simple and powerful tool that can often be learned easily, and that can facilitate significant positive change. A role where people specialise in low-intensity psychological interventions is new, but it’s got the hallmarks of an emerging profession. If we had regulation, registration, and accreditation like other health and social care professions, we could potentially gain independence from IAPT. This would mean that we would be in a position to help IAPT to do some effective self-reflection and change. Over the years I calculated that I’ve met more than 3000 people in one-to-one clinics and within groups that attended psychoeducation courses that I have facilitated. Contact with those people has done me good, as I have done my best to provide something valuable for them. The things that my patients have shared with me and the courage that they’ve demonstrated humbles me. IAPT is a visionary project that has done a tremendous amount of good and that has allowed lowintensity psychological therapies to find their feet. There is a line in the article by Marzillier and Hall (2009) that keeps coming back to me: ‘the reality is that psychotherapy is a skilled and often uncertain endeavour that demands a high level of interpersonal skills and a particular expertise’. When I think back to the low-intensity practitioners who I have worked with over these years, despite the many difficulties and challenges of working in an IAPT system, this is an accurate description of what has emerged in this workforce.

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Career Map for the Psychological Professions. Retrieved from https://ppn.nhs.uk/resources/careers-map/. Richards, D., Suckling, R., 2008. Improving access to psychological therapy: the Doncaster demonstration site organisational model. Clin. Psychol. Forum. 181, 9–16. Retrieved from https://ore.exeter.ac.uk/repository/bitstream/handle/10036/42082/Richards1.pdf?isAllowed=y&sequence=6. Richards, D., Whyte, M., 2011. Reach out: National Programme Student Materials to Support the Delivery of Training for Psychological Wellbeing Practitioners Delivering Low Intensity Interventions, third ed. Rethink Mental Illness, UK. Retrieved from https://cedar.exeter.ac.uk/media/universityofexeter/schoolofpsychology/cedar/documents/Reach_Out_3rd_edition.pdf. Richards, D., Farrand, P., Chellingsworth, M., 2011. National Curriculum for the Education of Psychological Wellbeing Practitioners (PWPS), second ed. UK. Richards, D., Bower, P., Pagel, C., Weaver, A., Utley, M., Cape, J., Vasilakis, C., 2012. Delivering stepped care: an analysis of implementation in routine practice. Implement. Sci. 7 (3). https://doi.org/10.1186/1748-5908-7-3.

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Richards, D.A., Ekers, D., McMillan, D., Taylor, R.S., Byford, S., Warren, F.C., al, e., 2016. Cost and outcome of Behavioural activation versus cognitive Behavioural therapy for depression (COBRA): a randomised, controlled, non-inferiority trial. Lancet 388 (10047), 871–880. https://doi.org/10.1016/ S0140-6736(16)31140-0. , August 27. Richerds, A., Barkham, M., Cahill, J., Richards, D., Williams, C., Heywood, P., 2003. PHASE: a randomised, controlled trial of supervised self-help cognitive behavioural therapy in primary care. Br. J. Gen. Pract. 53 (495), 764–770. Roth, A., Piling, S., 2007. The Competences Required to Deliver Effective Cognitive and Behavioural Therapy for People with Depression and with Anxiety Disorders. The IAPT Programme, York. Shafran, R., Myles-Hooton, P., Bennett, S., Ost, L.-G., 2021. The concept and definition of low intensity cognitive behaviour therapy. Behav. Res. Ther. 138. https://doi.org/10.1016/j.brat.2021.103803. , MArch. SHARP, 2006. Self-Help Access in Routine Primary Care. Retrieved from https://www.primarycare-selfhelp.co.uk/. Taylor, A., 2003. The primary care Programme of the National Institute for mental health in England (NIMHE). Primary Care Ment. Health 1, 1–3. The British Psychological Society, 2021. Find an Accredited Course. Retrieved from https://www.bps.org.uk/public/become-psychologist/ accredited-courses?type=WPW. The Department of Health, 2000. The NHS Plan: A Plan for Investment, a Plan for Reform. United Kingdom. The Department of Health, 2001. The Mental Health Policy Implementation Guide. Department of Health, United Kingdom. Thorley, A., 1978. Nursing in Behavioural psychotherapy: an advanced clinical role for nurses. By I.M. Marks, R.S. Hallam, J. Connolly and R. Philpòtt. Royal College of nursing research series. Behav. Cogn. Psychother. 6 (1), 20–21. https://doi.org/10.1017/S0141347300005048. University College London, Centre for Outcomes Research and Effectiveness, 2015. Report of the Psychological Wellbeing Practitioner Review – Phase 2. Department of Health, London. West, M., 2017. Leadership in Today's NHS. The NHS Leadership Academy. Retrieved from https://www.leadershipacademy.nhs.uk/leadership-todays-nhs/. White, J., Keenan, M., Brooks, N., 1992. Stress control: a controlled comparative investigation of large group therapy for generalised anxiety disorder. Behav. Psychother., 97–114. https://doi.org/10.1017/S014134730001689X. Williams, C., 2001a. Overcoming Depression: A Five Areas Approach. CRC Press. Williams, C., 2001b. Use of written cognitive–behavioural therapy self-help materials to treat depression. Adv. Psychiatr. Treat., 233–240. https://doi. org/10.1192/apt.7.3.233. Williams, C., 2003. Overcoming Anxiety: A Five Areas Approach. CRC Press.

Further reading Baker, C., 2020. Mental health statistics for England: prevalence, services and funding. In: Briefing Paper Number 6988. The House of Commons Library, London, United Kingdom. Retrieved from https://dera.ioe.ac.uk/34934/1/SN06988%20%28redacted%29.pdf. Bennett-Levy, J., Richards, D., Farrand, P., Christensen, H., Griffiths, K., Kavanagh, D., Williams, C., 2010. Oxford Guide to Low Intensity CBT Interventions. Oxford University Press, Oxford. Bernard, J.M., Goodyear, R., 1998. Fundamentals of Clinical Supervision, second ed. Allyn & Bacon Inc., Boston, MA, USA. Bower, P., Richards, D., Lovell, K., 2001. The clinical and cost-effectiveness of self-help treatments for anxiety and depressive disorders in primary care: a systematic review. Br. J. Gen. Pract. 51 (471), 838–845. Clark, D.M., 2011. Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: the IAPT experience. Int. Rev. Psychiatry 23 (4), 318–327. https://doi.org/10.3109/09540261.2011.606803. Gellatly, J., Bower, P., Hennessy, S., Richards, D., Gilbody, S., Lovell, K., 2007. What makes self-help interventions effective in the management of depressive symptoms? Meta-analysis and meta-regression. Psychol. Med. 37 (9), 1212–1228. https://doi.org/10.1017/S0033291707000062. Anon., 2021. IAPT Practice Research Network. Retrieved from https://www.iaptprn.com. Marks, I.M., 1987. Fears, Phobias, and Rituals: Panic, Anxiety and their Disorders. Oxford University Press, Oxford, United Kingdom. NICE, 2001. Commissioning Stepped Care for People with Common Mental Health Disorders. Retrieved from, NICE. http://www.swscn.org.uk/wp/wpcontent/uploads/2015/03/non-guidance-commissioning-stepped-care-for-people-with-common-mental-health-disorders-pdf.pdf. Richards, D., 2004. Self-help: empowering service users or aiding cash strapped mental health services? J. Ment. Health 13 (2), 117–123. https://doi.org /10.1080/09638230410001669246. Scott, M.J., 2020. Ensuring that the improving access to psychological therapies (IAPT) Programme does what it says on the tin. Br. J. Clin. Psychol., 38–41. Shepherd, M., Rosairo, M., 2008. Low intensity workers: lessons learned from supervising primary care mental health workers and dilemmas associared with such roles. Ment. Health Fam. Med. 5 (4), 237–245. Retrieved June 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2777579/. The National Collaborating Centre for Mental Health, 2020. The Improving Access to Psychological Therapies Manual. The National Collaborating Centre for Mental Health, London. Retrieved from https://www.england.nhs.uk/wp-content/uploads/2020/05/iapt-manual-v4.pdf. Tupin, G., Wheeler, S., 2011. IAPT Supervision Guidance. Improving Access to Psychological Therapies, UK. Retrieved from https://www.uea.ac.uk/ documents/746480/2855738/IAPT_Supervision_Guidance_2011.pdf.

Chapter 2

Defining success James Spiers

Key aims for this chapter ● ● ● ●

To consider what it means to be successful in low-intensity psychological therapy. Generate an understanding of the difference between statistical relevance and real-world clinical experience. Consider common problems with a stepped care approach to mental health. To highlight the potential benefits and costs of routine outcome monitoring when not utilised alongside qualitative data capture from patient lived experiences.

IAPT: Debating success The IAPT programme often divides opinion in the United Kingdom, particularly amongst the counselling and psychotherapy professions. Opinions also involve the historical, social, personal, and political lens of the people in those professions. At a very basic level, the main arguments around the success of the IAPT programme are primarily anchored in two camps. On the one hand, there is the ‘pro-IAPT camp’, which claims that despite the IAPT programme being imperfect and a work in progress (Clark et al., 2018), it replaced a prior system of poor access to therapy for people experiencing common psychological problems. The IAPT programme aims to offer transparency, is successful for over half of the patients that it treats, and despite some problematic aspects around logistics (mostly related to funding and wait times), it replaced a prior problematic system of limited access to psychological care for the wider general population, coupled with inconsistencies in the efficacy of the therapies on offer due to a lack of outcome monitoring and research. IAPT offers increased access to evidence-based treatment of mild to moderate mental health difficulties in addition to increasing access to those who would previously not have met the threshold for support (Clark et al., 2009). It tasks itself with large-scale data scrutiny that feeds into research to improve treatment outcomes and pays for itself by recouping its government funding by reducing lost revenue through unemployment and employment absence (Clark et al., 2007). The flip side of the debate comes from the ‘not-so-pro-IAPT camp’, who claim that not only has the IAPT programme failed to deliver on its promise of cost savings through employment benefits (Steen, 2019) but has also eroded traditional therapies such as counselling and integrative psychotherapy, monopolising the market with CBT and created employment problems for therapists who trained prior to the inception of the programme (Cotton, 2019; Rizq and Jackson, 2019). Not only does IAPT favour CBT but also uses a watered-down manualised version of therapy, with inadequate assessment and subsequent treatment of mental health disorders (Scott, 2018, 2021). The rapid domination of IAPT services has further eroded the investment in services aimed to support severe and enduring mental health problems, and the way in which the programme presents its data falls short of its claims on outcomes (Fotaki, 2019; Scott, 2018). Finally, the rapid advances in short-term manualised and digital-enabled therapies threaten community-based care, leaving traditional modalities of counselling and psychotherapy, and the patients who sit on the periphery of society, out in the cold (Campling, 2019), and the rise of industry pressure leading to services cutting costs and driving income through performance targets creates poor employment and working conditions for those on the frontline of mental health care (Cotton, 2019). These are simplified and paraphrased versions of the debates, and I cannot fully do justice to them within this chapter; I would urge anyone to engage in further reading around the compelling arguments on all sides. For those reading this from outside of the United Kingdom, you may be thinking how incredibly lucky we are to be having these debates at all. It is very easy to forget that we are a nation of people who live in a country where we have the privilege of being upset about waiting for weeks or months to gain a free [at the point of access] appointment with a psychological practitioner or therapist. We also have the opportunity to feel angry about the way our free therapy is delivered and to be equally concerned about how and why our therapy may or may not work. But the IAPT programme in England is not without its problems.

Care in High Volume. https://doi.org/10.1016/B978-0-323-88492-1.00002-6 Copyright © 2023 Elsevier Inc. All rights reserved.

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The business of wellbeing If your business is wellbeing and your brand has large access and outcome targets on a limited budget, you need to achieve those targets to retain your limited and target-dependent funding by getting enough of the right people coming through the right door to succeed. In IAPT services, at least 50% of the people entering treatment need to buy into, use, and fully benefit from the product. Staff need to produce consistent, standardised, high-quality work. Yet, if too many people access your wellbeing business, who may still benefit in some way but are unlikely to fulfil your output quotas and wait time directives, do not fully buy into your business model, and present with nonstandard histories and experiences requiring more time from your workforce than they are able to offer, then you have a problem. To solve the problem, you have the option of changing your business model, adapting your thresholds to accommodate patient needs, increasing your range of therapists to improve patient choice and the fluid shifts in patient presentations depending on the social and political landscape, all requiring further investment. Without that further investment, you may opt to stick rigidly to your brand identity and begin restricting the flow of the wrong people by bolting the door through your access criteria. My experience of working with, and alongside various IAPT services up and down the country is that once the pressure mounts around access and outcome targets linked to key performance indicators (KPIs), services typically opt for the latter.

Wrong doors IAPT service suitability assessments are primarily undertaken by low-intensity practitioners. During my time working in the IAPT programme, these regularly included assessment of people with severe and enduring mental health problems, substance and alcohol addiction, pending police investigations, reactive acute distress due to problems beyond the person’s control, housing problems, and homelessness, as well as people experiencing significant risk concerns, often steered in the direction of IAPT by well-meaning medical professionals due to a lack of options for secondary, specialist mental health, and social care service input. Many of my own service assessment sessions resulted in either signposting people to local charity organisations or writing referrals to longer term specialist services where someone either did not meet the access criteria for primary care services or where it was not safe for someone to be sat on an unmanned waiting list without support, due to significant risk issues. My appointments were often booked by staff in the GP surgeries and commonly offered as a stop gap whilst waiting for further assessment for specialist services, or the hope of temporary management of distress. For the most part, many of these patients would simply be discharged and fall back into an ever-widening gap between the service suitability of primary, secondary, and specialist services. Ultimately, many of my sessions were spent telling people that they were likely to wait upward of 12 months for further assessment, or that there was currently no service available to them at all. There were also many nonattended appointments, leading to further frustration and upset for GPs, service managers, practitioners, and the patients who were delayed in their waiting times as a result. Naturally, this was a challenging process for the people who were coming forward for help, and it also created stressed relationships between the IAPT workers and the primary care medical teams, particularly when explaining to GPs who were less familiar with the remit of IAPT services, as to why, as a psychological wellbeing practitioner (PWP) I was unable to help people in psychological distress. Essentially, a large portion of this patient group required extended assessments and safety planning, often requiring two low-intensity appointments for initial assessment and a follow-up for signposting or further referral. This client group then entered the IAPT national outcome database, due to being assessed over two or more sessions, therefore entering treatment, and the clock was now ticking on their recovery outcomes. Yet, none of these patients ever achieved statistical recovery given that they had never actually started psychological treatment with IAPT in the first place.

Right doors For the patients who I assessed who presented with mild-to-moderate range symptoms of anxiety and depression, the patient group who the programme was designed to work with, and statistically speaking the most likely to benefit from an IAPT service would more often than not already have some prior knowledge and attempts at self-help via Google searches or information previously provided to them by their GP. The range of expectations from patients during their initial service assessment tended to vary. Some had little intention of taking up psychological intervention and attended their appointment to placate a well-meaning relative or GP, whilst others were enthusiastic and were clutching to the hope of receiving formal



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counselling or psychotherapy, with the odd handful where their expectation was to leave their assessment appointment being fixed or undergoing ‘brain rewiring’. For the vast majority of people that I assessed deemed ‘suitable’ for an IAPT service, my experience was that most anticipated something more aligned with what traditionally would be thought of as counselling, sitting in a room for an hour a week to talk through their problems. Expectations beyond this would vary based on the person’s awareness and capacity for problem identification and personal change. For those who did manage to bypass guided self-help (GSH) as a ‘first-line intervention’, they would often then be left sitting on long waiting lists for high-intensity therapy without any monitoring or clinical input. The argument here around receiving intervention more swiftly is often used to justify earlier intervention through a ‘low-intensity first’ approach.

Locked doors Access to IAPT services commonly included significant numbers of people who wanted help with the symptoms of anxiety and depression but did not self-report sufficiently high enough on the routine outcome measures. This was also common when I worked as a trainee psychologist in secondary care and specialist services, with patients who were often unaware of their marked patterns of dismissing or ignoring the severity of their distress or needs, yet were commonly unable to gain access to an IAPT service, unless they met the clinical threshold of a score of 10+ on the PHQ-9 (Kroenke et al., 2001) and 8+ on the GAD-7 (Spitzer et al., 2006) or in IAPT language, ‘caseness’. Whilst the national IAPT guidance (NCCMH, 2021) does stipulate that the subjective experience of the patient, alongside objective clinical judgement, should always be used in conjunction with the routine outcome measures, if low-intensity practitioners are neither trained nor supported to assess beneath the surface, the risk here is not only that people cannot access the most appropriate intensity of therapy but also they risk being locked out of services altogether. Equally, people who may present with milder but chronic symptoms of depression or anxiety but wish to enter more exploratory therapy, perhaps due to problems in their relationships, inability to sustain friendships or romantic relationships, anger problems, fear of abandonment, and problems with sex and sexuality, there is little scope to readily access this on the NHS in primary care. That is unless a person can be allocated a specific problem descriptor and score sufficiently on routine outcome measures.

Revolving doors Whilst some aspects of the IAPT programme will fully meet the needs of some people in society and arguably can often be viewed as sense-making, that is, people with a common mental health problem refer themselves to an IAPT service, are seen quickly, start with a low-intensity intervention, and step up to formal counselling or psychotherapy, where necessary, the reality of my work with patients as a low-intensity practitioner often made less sense in clinical practice. NHS business modelling and service suitability criteria are typically based on maximising patient throughput for the least costs and within a limited budget. For the most part, this is achieved through target-orientated KPIs and pathwayspecific services. However, IAPT services are not in isolation in setting service suitability criteria. Secondary and specialist mental health services also have a minimum threshold based on presenting diagnoses, for example, schizophrenia, bipolar disorder, or physiological features such as minimum body mass index (BMI) to access eating disorder services. Also, where patients who experience severe problems with obsessive compulsive disorder (OCD) or body dysmorphia (BDD) have engaged with a prior uptake of primary care CBT-based intervention and whether any lack of gains from that treatment are likely to be countered by more specialised input. Crisis and acute inpatient services will also assess patients’ suitability for access based on their presenting degree of risk towards themselves or others, and the nature and history of crises. Where resources are limited and waiting lists are high, naturally there needs to be a process of filtering, the NHS is, of course, a finite service. Yet, the efficacy of the IAPT programme is often the headline when criticism is raised around access criteria, despite similar processes across mental health care more broadly in England. This is particularly important to consider when patients who would typically not have previously been referred to an IAPT service due to the more acute or severe nature of their presentation and the likely requirement of higher tier psychological or psychiatric input are increasingly presenting for low-intensity assessment (Martin et al., 2022). However, the clinical reality from my own experience in the low-intensity role is that for a large number of the patients who may likely benefit from the IAPT programme, many never make it beyond the revolving front door.

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The journey to IAPT: Kasia’s story Whilst the case of Kasia is fictionalised, her experience during the assessment appointment is not an uncommon scenario in my personal experience of working in IAPT services. Her relaying of the experience afterward and the strained relationships with family members who are paying for her therapy are more common in my experience as a therapist in private practice. Kasia’s data would be entered into the national statistics as one of the very high numbers of people who access an IAPT service for one appointment only, being discharged after the second nonattended group session (Box 2.1).

BOX 2.1 Kasia attends her GP surgery for help with recurring episodes of depression. She has been very reluctant to access therapy in the past and has managed her symptoms for many years by keeping busy, overly caring for others and engaging in excessive overeating when she is struggling to manage. Following her divorce 4 years ago from a coercive and controlling relationship, her adult children have since moved out of the family home. Kasia’s symptoms of depression steadily worsened after her youngest daughter moved out around 6 months ago, and Kasia’s previous ways of coping are no longer working. She explains to her GP that she has stopped leaving the house, is struggling to get out of bed in the morning, has been disciplined at work for being late, is currently off sick, and does not feel able to return, requiring a sick note. Having had numerous discussions with her GP previously about her depression and reaching the maximum limit for antidepressant medication, her GP suggests that she tries psychological therapy to explore the root of her problems. Kasia explains to the GP that there are events in her past that she feels she has never properly addressed, including the relationship with her mother, but will need to build up trust with a therapist to fully discuss this. She does not have the financial means to access private therapy and as this is the first time she has seriously considered therapy, is able to generally function, and does not have a history of self-harm or suicide, her GP explains to her that her only option (based on local resource availability) is to access her local IAPT service. This would involve a service suitability assessment and potentially engaging with low-intensity interventions first, under a progressive model of stepped care. Kasia asks the GP if they can write a referral to the IAPT service specifically requesting counselling. The GP explains that the local IAPT service is now self-referral and where they have previously specified a therapeutic approach it has made little difference. Kasia is disappointed but trusts her GP and makes a self-referral to the IAPT service. Kasia is seen at the GP surgery for her IAPT assessment appointment and is greeted in the reception area by a low-

intensity practitioner. The practitioner is warm and friendly, and Kasia feels able to say that ideally her aim from the appointment today would be to access counselling. She further explains that she is aware the NHS is pressured and there is likely to be a waiting list, but would prefer to wait. After completing a five areas conceptualisation, that is contained only to the obvious links between lowered physical activity, self-critical thoughts, and low mood, the low-intensity practitioner outlines a clear rationale for low-intensity intervention. Kasia explains that she sees the sense in this but it is not what she was hoping for. The low-intensity practitioner then becomes a little more assertive and explains, ‘it is a stepped care model’. Kasia now feels anxious that she has offended the practitioner and that protesting any further might lead to her being perceived as ungrateful. Kasia does manage to speak about how she has a tendency to put others before herself, currently hiding in the house due to the shame that she feels about letting her employer down, due to unmanageable depression. The practitioner explains that NICE guidelines recommend low-intensity intervention first, particularly where depression is concerned and points out that Kasia stated herself that one of her goals was to return to work. Kasia leaves the appointment having agreed to four, weekly group sessions on the Managing Your Mood course. She clutches her Food for Thought NHS psychoeducational material printed from the internet during her appointment and thanks the practitioner for their help. Kasia swiftly exits the surgery and bursts into tears in the car. She never attends the Managing Your Mood group. A few weeks later she attends a medication review appointment with her GP and explains her experience with IAPT. Her GP suggests that they could give feedback to the IAPT service and request counselling. Kasia feels this would burden the GP and potentially lead to the practitioner getting into trouble, and politely declines. Her symptoms of depression persist, and whilst the relationship with her mother has always been strained, she reluctantly borrows money from her to access a private counsellor.

Urban myths: A panacea Admittedly, I spent many years complaining about IAPT services whilst working in them, with many attempts at trying to highlight the harms of the systems and processes as I saw them. But do IAPT services that batten down the hatches on service suitability criteria run the risk of iatrogenic harm? This is a difficult question to consider and will depend on the lens that you are viewing the question from. My personal lens is that when someone’s experiences are circumvented to meet the needs of systems and processes or are locked out of available care because their experience does not fit with the business model of the healthcare system, then we risk not only harmful messages to patients but also the normalising of dehumanising processes.



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What began with a revolutionary idea within English mental health services, has become warped under the pressure of the crumbling infrastructure of England’s health and social care provision, resulting in a new referral behaviour of all roads leading to IAPT. That road most often begins with low-intensity intervention, which (like any other psychotherapeutic modality) has significant limitations where the person’s opportunity for change is heavily hindered by history and individual factors. An urban myth has formed, with low-intensity psychological practice being positioned as a panacea for anyone presenting with the symptoms of a common mental health problem. Yet, there is a financial argument here, short-term relief from distress for the patient, longer-term relief on the pressure of GP resources, and less need for prescription medication subsidised through the NHS. The difficulty, however, is that primary care NHS GPs often have their hands tied when it comes to a progressive stepped model of mental health care, with IAPT services often being the only available option for their patients resulting in continuous streams of patients knocking on revolving doors.

Progressive stepped care Progressive stepped care is the more commonly adopted approach to psychological therapy in primary care health services in England, and refers to an incremental progression of treatment based on the presenting problem, with the aim of patients being offered the least invasive but most appropriate treatment, particularly when concerning depression, see NICE (2021). A medical example here might be where someone in their twenties presents to their GP with persistent heartburn. From the symptoms and general assessment, the GP feels that the most likely reason is the patient’s high-fat diet and stressful lifestyle. The person is offered dietary advice, and tips on lifestyle change and told to take antacids for a few days. The person’s problem then resolves. They receive the least invasive treatment based on a thorough assessment and expert knowledge, avoiding invasive scans and surgery. If the problem then recurs, worsens, or no longer responds to antacids and dietary changes, the GP may then refer the person for further testing.

Stratified stepped care A stratified model of stepped care, see Delgadillo et al. (2022), still adopts the same ‘right care at the right time’ approach but is more focused on the right intervention as opposed to the least invasive, based on the presenting problem and dynamic factors that are present in the person’s individual context. This is nearer to the interpretation of stepped care within physical health settings in the United Kingdom. For example, take the original scenario of the 20-year-old patient with heartburn. Instead, the patient is in their late 50s, is overweight with high blood pressure and has a family history of heart disease. Here, the GP has the option to bypass dietary advice, lifestyle change and the antacid and send the person for further assessment with a heart specialist. Here, a more invasive assessment is being offered for the same presenting symptoms as the 20-year-old, on the basis that there are dynamic factors at play based on the characteristics of the 50-year-old patient. Therefore, the increased intensity of care is proportionate, timely, and appropriate to the presenting symptoms of the individual.

Challenges with progressive stepped care in IAPT The difficulty with a blanket approach to progressive stepping in IAPT services is that in the majority of cases, patients undergo an assessment with a low-intensity practitioner. Yet, low-intensity practitioners are neither qualified, equipped, nor have time to assess the nuances within the broader context of symptoms or history relating to psychopathology, to reliably determine the step of care required. This is not to undermine the high skill and ability of low-intensity practitioners to formulate and identify current problems and the likely maintaining factors of distress, more that they are specifically trained to do this with the day-to-day symptoms of mild-moderate presentations of anxiety and low mood only, regardless of their aetiology. Which, both anxiety and depression feature in most forms of human psychological and emotional distress, ranging in severity and the chronic nature and source of the problem/s. To labour the point here, let’s take another look at the medical example of heartburn within the context of a low-intensity assessment based on the progressive stepped care approach that is commonly adopted in IAPT services. The 50-year-old patient with a family history of heart disease attends with the same symptoms of heartburn as the 20-year-old. They both undertake the same standardised assessment, and both are asked to contain their experience to the most pressing thing that they want help with in the here and now (heartburn). Rather than seeing a GP or nurse practitioner, both patients are assessed by a Living Well Practitioner, an allied professional with a good working knowledge of specific problems with digestion and skilled in lifestyle change, healthy eating, exercise, and stress reduction techniques, but little awareness and

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training in diagnosing and treating more serious conditions. A very brief history is taken from the 20-year-old and 50-yearold patient because this is simply a brief triage appointment. Both cases are then managed in case management supervision by a more experienced Living Well Practitioner, again, as opposed to a nurse practitioner or GP. The supervisor agrees that both patients appear to present with symptoms in keeping with what they would commonly see in their clinics (heartburn). They discuss that the 50-year-old patient may require further assessment but it is better if they are seen quickly, are still likely to benefit, and can be stepped up to see the GP if there is no improvement. Both patients are then offered a 4-week group intervention run by the Living Well Practitioner starting the following week, covering dietary change, lifestyle tips, and advice around stress reduction. After the course ends, the 50-year-old patient experiences similar relief from their symptoms of heartburn as the 20-year-old, which is the same as around half of the other patients at the surgery who have attended complaining about heartburn. Both patients are treated and discharged swiftly without the need for further assessment or invasive tests. The practice, therefore, claims that the Living Well Programme is a highly successful system of treatment for their patients. The 20-year-old patient maintains a heartburn-free life and feels the added benefit of improved mood from stress reduction. The 50-year-old patient subsequently increases their activity level following weight loss from their dietary change but suffers a heart attack 3 months later due to a clogged artery that required a stent. Are we still in the territory of success? Or inappropriate care and iatrogenic harm?

Stepped care: My [un] successful experience The progressive model of ‘low intensity first’ stepped care that has silently been normalised over recent years in IAPT services has been, in my opinion, a perversion of what stepped care was intended to be. This is not to offer some broad generalisation of ‘all IAPT services’, there are still some remaining services where a more stratified approach is used. However, it is becoming increasingly adopted and at the time of my recent departure from the fifth IAPT organisation I have worked with, each has adopted (or the services they work on behalf of have adopted) a low-intensity first approach, where more or less everyone accessing an IAPT service will typically start with a low-intensity intervention. Over my time in IAPT, I have personally witnessed countless patients commencing LICBT regardless of whether it is the most appropriate step of care for the patient or not (Box 2.2).

BOX 2.2 In 2018 I made the decision to retry CBT for health anxiety, something I had problems with since around the age of 12 years old. Having accessed CBT privately in my early thirties, I had found this helpful to a degree, but admittedly had not fully engaged with the out-of-session work. I was not working in psychotherapy at the time, was sceptical of therapy, and treated it as more of an inconvenience than something with the potential to help. Now, with some experience as an IAPT practitioner under my belt, a lower disposable income, and unable to afford private therapy, but still convinced that every headache was a brain tumour, a new blemish on my skin might be malignant melanoma, I decided this was the right time for me to fully embrace what CBT could offer. Motivated for change, I self-referred to my local IAPT service and was offered an appointment with a low-intensity practitioner. Having worked in the low-intensity role, aware that lowintensity assessments are time pressured and focused on a specific problem, I had pre-completed the Health Anxiety Inventory (HAI; Salkovskis et al., 2002) in advance of the appointment, alongside the PHQ-9 (Kroenke et al., 2001) and the GAD-7 (Spitzer et al., 2006). Despite preparing key points as to the intrusive and obsessive nature of my thoughts, and the challenges I experienced with the compulsive nature of my ac-

tions, we appeared to land firmly on the tracks of the five areas formulation and problem description for moderate generalised worry (based only on the GAD-7, a brief screening measure for generalised anxiety). It was an odd experience, and for a moment I was almost in agreement with the low-intensity practitioner that I had in fact misjudged my problem, including the judgement and expertise of my GP who knew me well and had previously dealt with my diagnosis and recommended CBT treatment. I pointed out to the practitioner that my scores on the HAI were well over the clinical threshold, and my primary goal was to be able to reduce obsession and compulsion related to a long-term problem with health anxiety, with my primary aim for the appointment being able to gain access to CBT for health anxiety in line with NICE (2014) guidance. The practitioner did not wish to take my precompleted HAI over the telephone, stating that the policy in their service (in contrast to the service I worked in at the time) was that they only undertake routine outcome measures at the assessment appointment. Based on these, combined with my five areas formulation related only to a recent worrying thought, had indicated a clear rationale for low-intensity therapy first, and therefore I was to be offered the stress course. I protested,

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BOX 2.2—cont’d e­ xplaining that I was a low-intensity practitioner in a nearby IAPT service, and whilst not wanting to come across as trying to tell them how to do their job, I had delivered the stress course on many occasions and had utilised the techniques regularly to manage the general stress of the role, I could not see how this would help me with my aims for treatment. The practitioner became quite assertive and countered this by telling me that, as a low-intensity practitioner, I should know ‘this is stepped care’. After some to and fro, the practitioner suggested that they take my case to case management supervision. A week later I received a call to say that I had been accepted to the CBT waiting list and to expect a wait time of around 18 months. A year later, I received two letters through the post at the same time, both franked with the same postal date. The first letter stated that I was being discharged from the waiting list. The

other, dated 2 weeks prior, was asking me to contact the service to opt-in within the next 14 days or risk being discharged from the service. Aware that 14-day waitlist opt-ins were common practice in each of the services I had personally worked in, and given the franking dates, it was highly likely to be an unintentional error. At this point, I had started my doctorate and would be undertaking personal therapy as part of the course. I was short on time and simply couldn’t be bothered to complain. However, I was left thinking that if I had struggled to get my point across in order to access an appropriate treatment pathway as a clinician actually working in the IAPT programme, to then also be discharged from that pathway due to an administration error, then how would a patient navigate all of this where they may not have the same knowledge and understanding of the likely pressures that influence that system?

Evidence for progressive care in IAPT Shortly before leaving the IAPT service where I had spent the majority of my career in low-intensity practice and an influencing factor in my leaving, was the adoption of the low-intensity first progressive model of stepped care. Alarm bells began ringing for many of the staff members, with increasing numbers of staff leaving the service, many expressing deep concern around the adoption of the new model. When I, and several of my former colleagues asked to review the evidence base underpinning such a major change to the service model, one of the service leads referred us to a paper by Boyd et al. (2019), claiming that a progressive low-intensity first model of stepped care had improved outcomes since its adoption. At the time, the paper was published in an online Italian journal. The limitations outlined in the paper by the authors were transparent, an observational study undertaken in a single service where there was high staff attrition, mostly involving trainee low-intensity practitioners, with small increments of patient recovery outcomes being noted, similarly tracking the small increase to the national recovery rates on NHS digital. The paper also reported the main challenges during the period observed being the protests and objections from experienced clinicians working within the service. Essentially, the paper read all too familiar with what was happening in the service where I was based, with the same objections being raised by experienced staff. Yet, facing intense pressure to achieve KPIs, the service had ploughed ahead regardless. Ultimately, the evidence base for the low-intensity first progressive care model had been formed through yet another urban myth based on a single observational study and generalised assumptions made from interpretations of the national data reported by the data managers in IAPT services, neither of which can offer any discrimination between the outcomes for low and high-intensity interventions given that both the data in the paper and the national data reported by services is aggregated. Whilst there is currently no ideal model of health care with an ideal and endless source of funding, the simple and seamless concept of a progressive stepped care model, for many, is more of an assault course than an ideal. That is unless we offer greater flexibility within the system at the first step. In the United Kingdom, private therapy can only be accessed typically by those with disposable income or insurance, but equally, it is more difficult to control and monitor the quality of the work due to the very limited regulation of psychological therapy in the United Kingdom. Quality training and delivery of psychological therapy are more easily monitored (to a degree) in the NHS, but access to it, certainly to therapy that is delivered in line with its evidence base, is steeped with many barriers. For those who do not have the financial means to step off stepped care, they are left with little choice or option but to navigate often very rigid processes designed for high throughput for the least cost. In an ideal world, the patient accesses an IAPT service and receives swift access to psychological assessment and treatment, often through self-referral where they bypass the need for any discussion with their GP. In theory, this model works like a well-oiled machine, provided that the patient: 1. Presents with a common mental health problem. 2. The patient accepts that their primary concern is a surface-level problem that they also understand as general worry, panic attacks, depression, or stress.

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3. They want to/are prepared to work in a CBT-informed way. 4. They do not want to focus on their wider historical context, and experiences, or explore links between historical trauma and the here and now. 5. If they do wish to discuss the link between historical trauma and the here and now, they are prepared to hold onto this for around 6 months whilst waiting for, and then undertaking low-intensity intervention first, before entering another waiting list for high-intensity assessment. 6. Their scores on the PHQ-9 and GAD-7 do not temporarily abate during the low-intensity intervention, leaving no ‘objective’ rationale in case management supervision for stepping up to high-intensity therapy. If their scores on routine outcome measures do show recovery they are discharged with a ‘consolidation period’ which may result in returning to the service at a later date. If they return with a different problem, or the same problem beyond a 12-month period, it is very likely they will start again with a low-intensity intervention. 7. The person does not prematurely drop out of treatment, also including those where it is the wrong, revolving, or locked door. 8. The person is able to secure evidenced-based treatment as recommended by NICE guidance (see point 7). But does this system offer a patient choice from taxpayer-funded health care? Imagine for a moment if we applied the low-intensity first model of progressive stepped care to the concept of trading on a market stall (Box 2.3).

BOX 2.3 Market trader (MT): Roll up roll up, finest fresh fruit sold here! Customer (CM): Hi, could I please have a bunch of your finest grapes? MT: I have some really great tomatoes; would you like to try a tomato? CM: Ah, no thank you. The last time I had tomatoes I got sick, I would like a bunch of your finest grapes, please. MT: Ah! Well, you see, this is a stepped choice fruit stall! CM: Stepped choice? MT: Yes, stepped choice. We offer the fruit that most other people choose, first. Then you can try the other products we have in our range, based entirely on customer choice, of course! CM: But tomatoes make me sick, can I have the grapes first? That would be my choice. MT: We have a lot of evidence to suggest that tomatoes are tolerated by half of our customers. Maybe try a tomato again? If you get sick you can join the queue for our oranges. CM: Oranges? I wanted grapes. MT: Evidence also suggests that people who get sick from tomatoes would be better off eating oranges, not grapes. There are more vitamins. CM: Are you saying I can’t have grapes even if I have a tomato? MT: No, not at all. I’m saying that we are an evidence-based stepped choice stall. We only offer what the majority of people choose and what half of our customers have found good for them. We operate a gold standard.

CM: Can I just join the queue for the oranges? I really don’t want tomatoes. MT: We recommend the tomato first. CM: Are you saying I can’t have either grapes or oranges unless I have the tomato first? MT: No, not at all, I’m simply saying that most of our customers choose tomatoes first and the evidence suggests that oranges are better for you than grapes. CM: Okay, fine, I will have the tomato so long as I can queue for the oranges afterward. MT: We can’t guarantee that you will be able to queue for the oranges straight away. CM: Eh? How come? MT: You might enjoy the tomato. If you enjoy the tomato, then you will have to wait to rejoin the queue again. CM: Re-join the queue for the oranges, or the grapes? MT: For another tomato. CM: For another tomato? You said I could get the orange if I had the tomato first. MT: We can’t be sure that you won't benefit from the tomato again. CM: Fine! Whatever! Just give me the damn tomato MT: So you’ve decided to choose the tomato? CM: Sure! MT: That’s great! The queue for the tomatoes is over there!

Defining success: Low-intensity intervention What is the evidence base for low-intensity cognitive behavioural therapy (LICBT)? Whilst the study by Boyd et al. (2019) has many limitations in being able to robustly claim that low-intensity intervention first, leads to improved outcomes more generally within IAPT services, there are some data to suggest that low-intensity intervention has been successful when implemented outside of the United Kingdom, including, Hong Kong (Powell et al., 2021) and Australia (Baigent et al., 2020). Yet, the longer-term nature of lasting effects, when compared to CBT, have been found to be twice that of the relapse



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rate of CBT over the following 24-month period since discharge (Ali et al., 2017; Delgadillo et al., 2018), with around half of people undertaking LICBT relapsing within the first 12 months, and 79% of those cases relapsing within the first 6 months following treatment. There are currently no published studies to consider which of the low-intensity interventions are effective, for example, discriminating between behavioural activation (BA) and cognitive restructuring (CR) for depression, worry management or graded exposure for anxiety-based problems. There is some indication to suggest that guided self-help (GSH) alone, without the human element does not produce the same statistically significant benefits in the short term (Koelen et al., 2022), and the limited available literature as to the real-world efficacy of GSH, there has been one randomised pilot comparison study between brief person-centred counselling (PCC) and LICBT in primary care populations (Freire et al., 2015) that suggested little difference in clinical outcomes. Given the limitations of GSH alone, and the differences in approach between the dyad relationship of PCC versus the triad relationship of supported LICBT, one might suggest the common factor here is the human element. My own experience, and is also the experience of Liz, and many other of my former low-intensity colleagues is that patients are often less focused on using workbooks and LICBT material, and the work typically becomes a blend of the human interaction with individually selected elements of CBT technique alongside. In my own practice, I would regularly spend a lot of time defining the problem, that is, what are we in agreement on that the person would like to change? The barriers to change, what is in the way of the person changing? And, can a brief CBT-based technique help to provide the person with a framework to target what the person has identified as the problem they are motivated to change? If so, and the patient is in agreement, I would use two to three individual worksheets as a maximum, modelling the technique in session as opposed to giving out reading material (that was rarely ever read). Essentially, if the patient understood what I was saying in real terms and that they could tell me how this applied to their life in real terms, then more often than not we were pretty much cooking on the gas towards a good outcome for the patient. This is certainly the way that I worked for the majority of my career as a low-intensity practitioner and consistently achieved well above the national outcome targets. Yet, I have absolutely no idea as to whether any of those patients benefitted longer term, given that IAPT services rarely gain data following discharge.

Defining success: Routine outcome measurement Anyone having worked or delivered low-intensity therapy in an IAPT service needs no introduction to the PHQ-9 (Kroenke et al., 2001) and GAD-7 (Spitzer et al., 2006) screening tools. These are mandatory screening tools used at every IAPT appointment and form part of a set of measures called the minimum data set (MDS). The PHQ-9 and GAD-7 serve three primary functions as part of an IAPT episode of care. 1. For the patient and practitioner to objectively monitor symptoms and progress. 2. For the service to monitor progress and outcomes. 3. For the service to get paid for the patient’s appointment and an episode of care. Another benefit of large-scale data capture across services is that they can then be used to support research using service outcomes to map trends in recovery rates based on local services that feed into national data around trends and outcomes nationally within England, ‘the evidence base’. These data are then available for public viewing on the NHS digital dashboard (https://digital.nhs.uk), offering transparency. By and large, the success portrayed by the IAPT programme through large outcome data statistics also includes large amounts of patients discharged from low-intensity practice. Yet, there is little to no research to reliably account for its longer-term success with patients. So is routine outcome monitoring a reliable indicator of success?

Psychoeducational groups One of the staple offers of most IAPT services is the large didactic psychoeducational stress courses. They are comprehensive, readily accessible and large numbers of people regularly attend them, many through self-referral. Psychoeducational groups can provide rapid access to supportive treatment of anxiety and depressive symptoms and have been found to generate stable and consistent short-term outcomes in IAPT services (Burns et al., 2016). They also generate a considerable amount of patient data that contribute to individual service targets. Technically, we might argue here that these are popular in IAPT services as a shared benefit to both patients and services. The techniques are typically CBT based and cover most of the low-intensity interventions over four to six sessions lasting an hour and a half, to two hours per session (Box 2.4).

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BOX 2.4 During my IAPT training year, I co-facilitated several psychoeducational stress management courses. Amongst the many attendees was John, an unemployed young man whose brother completed a self-referral to the course on John’s behalf. John had a psychiatric diagnosis of schizophrenia and with the support of his brother had been managing to live successfully in the community for the past 12  months, taking antipsychotic medication combined with regular reviews with a community psychiatric nurse (CPN), who had recommended the stress course. John attended the course twice during the time I was training in the service, both times attending with his brother who filled in the routine outcome measures to register John’s attendance. John’s outcome scores never changed (and technically were not John’s self-reported scores) but alongside his brother, John attended every session, twice. At session three of the first course, John’s brother approached me during the break to clarify something I had said during my presentation. It turned out that John was confused, having had years of CBT on and off during inpatient admis-

sions he had spotted a rookie mistake that I had made when outlining the link between thoughts, feelings, behaviours, and specific situations. We had a pleasant discussion, I thanked John for his eagle eye and was able to address the error for all attendees during the second half. John’s brother also explained that whilst John was well versed in the basics of CBT, his main intention of accessing the course was to integrate socially outside of a hospital setting, but felt safer doing this within the context of a psychological health service. Selfreferral being a way in which he could utilise the NHS without the need for lengthy and intrusive assessment processes, accessing a service based in primary care helping him to feel more ‘normal’. Essentially, the meaningful element of the stress group for both John and his brother was one of grading down from higher tier services to be amongst people living in his local community, but in a way that he felt he had some control over this and where his diagnosis would not hinder him from being able to access it.

Was low-intensity psychological intervention successful for John? There were hundreds of people who accessed the stress courses who I never actually met, faces in a crowd depending on the service and venue. Many of those who ­statistically met reliable recovery were discharged without further contact at the end of the course and therefore the service has absolutely no understanding as to the degree of their longer-term outcomes. There were also many people who did not reach the clinical recovery threshold on the PHQ-9 and GAD-7, including John, but left comments on their feedback forms about how they felt they had benefited from the sessions. All of whom would be recorded in the national outcome statistics on NHS digital as a therapeutic failure. For John, this was more difficult to determine. There was nowhere for John to indicate on his routine outcome measures that despite his persisting symptoms of depression, he had an improved sense of community belonging. There was nowhere for John’s brother to indicate his experience of increased pride for his brother, and the reduced pressure and worry for John’s mother (Box 2.5).

BOX 2.5 Heather, a middle-aged accountant attended a low-intensity assessment via a referral from her GP, in the hope of accessing one-to-one therapy. Due to her MDS scores on the very cusp of the clinical threshold PHQ-9 (9) and GAD-7 (6) had subsequently been offered the stress course by the assessing practitioner, as this was her only option due to her not meeting ‘caseness’. Heather approached me after the first stress course session and curtly said: No offence, but, you’re not telling me anything I can’t get on Google. I don’t want to do all this homework stuff, it’s like being at school. My GP recommended CBT one-to-one therapy and I want to be put on the waiting list for that!

My attempts to explain that the course was based on CBT principles and that one-to-one CBT would still be structured with out-of-session tasks, were met with protest. I then suggested that she could book another assessment appointment to discuss her needs in further detail, obviously being unable to assess her whilst we were standing in the middle of a large meeting room with other people and 10 min to go before the lights went out. Unfortunately, this seemed to further fuel her annoyance. She threw the workbook on a nearby seat shouting, “you know what, forget it! No wonder the NHS is in the mess it is in!” and walked briskly out of the building.

Was low-intensity psychological therapy successful for Heather? Following a call to her the next day, she was upset due to the embarrassment of her outburst. Going back to my earlier comments about many of the people I saw in IAPT services who neglected to apply any focus to the severity of their distress or problem, including their sense of the impact when completing their scores on the routine outcomes measures, my pause to point out the incongruence between what she was saying and what she was scoring led to a further outpouring of tears on the phone. Heather admitted that she felt unworthy

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of care, “I have a great job, I have no reason to be depressed.” We completed her outcome measures, with Heather being more honest about her experiences, this then created a position for the service where Heather was now in what the national outcome database would deem to be reliable deterioration. This was due to a significantly negative shift in her scores (her scores increased from being under the clinical threshold at the start of treatment to moderate-severe depression at her third measure). She was however now able to access the counselling team at the service following a lengthy case management supervision involving the clinical lead. Unfortunately, Heather did not attend her counselling sessions and entered the national database at discharge as having experienced psychological harm.

Individual guided self-help During my one-to-one clinics, I rarely saw anyone like John, but I have met many Heathers’ and a high volume of people in between (Box 2.6).

BOX 2.6 Numan, an early career lawyer who was preparing to sit his final exams at the time of his assessment and was at ‘caseness’, PHQ-9 (12), was offered the stress course but preferred the idea of one-to-one. By the time he was seen for his first session 8 weeks later which comprised a problem statement, goal review and intervention plan, his exam period was ending and was already near recovery PHQ-9 (10), by his second treatment session was in recovery PHQ-9 (6) having applied literally no LICBT intervention. Numan’s outcomes were entered into the national data as statistically reliable recovery, a complete success. Then there was Sue, an older adult who entered treatment severely depressed after a long period of isolation following the death of her husband but also experienced chronic pain. By session seven was cleaning her house again using pacing techniques and had joined a local gardening group through a local charity that I had introduced her to. Her scores on the PHQ-9 had shifted considerably, but due to disturbed sleep and problematic appetite due to ongoing chronic pain and the effects of pain medication her scores did not shift sufficiently to recover. Sue entered the national database as a therapeutic failure. Jerry, a 63-year-old retired steelworker was made redundant ten years ago and had set himself up in business as a

s­elf-employed handyman. Five years later, his wife died of breast cancer, and their only son moved to Australia. Jerry had an arthritis flare-up, stemming from an old back injury from the steel works, becoming so problematic that he had to give up his business. He barely managed on state benefits and felt shame for having depended on them. He started to feel worthless and had become isolated. Jerry’s GP had suggested that he may not have dealt with the loss of his wife, having not ‘properly grieved’ and suggested person-centred counselling. However, Jerry did not like the sound of counselling, “I’m quite a private person and don’t like talking about how I feel.” However, he was tentatively open to learning some practical techniques to help him manage his low mood. After eight low-intensity sessions, Jerry had established pacing, a routine, and mild exercise, and (with a little persuasion from me) had joined the local food bank as a volunteer, doing light casual maintenance where and when he felt he could. His final MDS scores were PHQ-9 (10), and GAD-7 (2). Despite the significant reduction in his scores and a moving expression of qualitative feedback, he was another failed statistic. Jerry was now contributing to his IAPT services outcome data as reliably improved but not recovered.

It would be easy (and human) to start making value judgements about each case. We might start to suggest that there was not a clinically relevant problem evident with Numan, he was likely suffering the very normal effects of exam stress and this subsided once the stress had passed, with very little likelihood of his decrease in stress stemming from his sessions in IAPT. It is also common in psychotherapy that people who experience reactive distress will score higher on the psychometric measures, but these subside once the stressful event has passed. Equally, we could suggest that Jerry was a genuine case of depression, he applied the techniques, pushed himself beyond where he was comfortable, gained an occupational activity that was valuable to him and increased his social network. His resulting success was evidenced by both his quantifiable reduction in measures alongside his qualitative sense of recovery and improvement. Whether the sessions offered human connection, provided purpose, or simply acted as a platform to reflect, Sue’s case would likely be most therapists’ idea of a case that went well. Essentially, John, John’s brother, Heather, Numan, Sue, and Jerry, like all members of our communities, are deserving of care. The degree of successful treatment we could apportion to LICBT, however, is less clear. A long-standing question for me here, is whether the problems with routine outcome measures in IAPT service ­outweigh their general utility in terms of increasing access to psychological health care? Is there more of a risk of disconnection between the healthcare system and the patients accessing it? Ultimately, IAPT services nationally appear to be faced with

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ever-increasing demand from new referrals combined with limited provision within the wider health and social care sector. As a consequence, there will likely be significant pressure felt by individual services and service managers to achieve results conducive to the continuation of commissioning, whilst trying to retain sufficient numbers of low-intensity workers to do this. So, can low-intensity psychological therapy be successful? From my subjective standpoint of working in the role, I would say that if it is well matched to the patient, and this is something that the patient is truly choosing to do, then I believe that it can be successful, at least in the short-term. However, my personal view is that there is further work to be done to consider its efficacy as a stand-alone treatment beyond the mild and recent onset of panic attacks, generalised anxiety and low mood. This is not to suggest that low-intensity therapy is the metaphorical sticking plaster, if we consider common occurrences of psychological distress manifesting from acute pressures, for example, workplace stress, life events, and common phobia, which the low-intensity programme was aimed to treat, then I would suggest that it does what it says on the tin and can offer very useful and swift relief here. However, it has limitations in its current form, one of those limitations being its use to manage waiting lists and its adoption as a mandatory ‘give it a go’ starting point for people with severe, chronic and complicated problems when accessing an IAPT service. This holds significant potential to undermine patients, lowintensity practitioners, and the wider psychological professions and speaks to a system of neglect rather than care (Fig. 2.1).

FIG. 2.1  Dehumanising process of progressive stepped care.

Re-humanising systems But what of the low-intensity practitioner? How do we expand on the role and build on what we have? How do we work towards a less target-driven, more pragmatic approach as we edge towards the five-year forward? To become more successful, at least success as defined by the patient’s experience is most likely to involve changes at a systemic level, better integration of services and the upscaling of low-intensity approaches to treatment. However, here we start to enter the territory of overlap with the broader profession of counselling and psychotherapy. For example, we might consider the potential of the current trials and upcoming introduction of guided self-help cognitive analytic therapy (GSCAT) as a way of increasing choice and variety for both patients and practitioners. Increased patient choice has previously been found to be a potential contributing factor to improved outcomes (Cooper et al., 2018). Whilst I do advocate for better patient choice, I also struggle somewhat with the concept of increasing the range of intervention at low intensity (beyond that of LICBT) and whether this would lead to better outcomes and systems. Thinking back to my days as a low-intensity practitioner, I would (and did) consistently advocate for diversifying the low-intensity



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remit. Partly due to my own sense of restriction in the role, and partly because, like many of my colleagues, I found that CBT-based intervention was less popular with patients, many of whom had either already attempted CBT-based self-help or had already unsuccessfully gone through a course of high-intensity CBT treatment previously with an IAPT service. Whilst my understanding of GS-CAT is that this continues to adopt a manualised approach, also utilising CBT-based techniques, my take here would be that whilst it is a similar format to the current model, the potential for clinical drift here becomes greater, and the temptation for low-intensity practitioners to delve into a deeper exploration of the patient’s early experiences in relationships during the session will likely be strong. On the one hand, I advocate for upscaling the knowledge and understanding of low-intensity practitioners, particularly their understanding of their own interpersonal dynamics, a better understanding of the theory and concepts that underpin the method of change being delivered, helping to sharpen the eyes and ears of practitioners when assessing for barriers to change. On the other hand, my sense is that if we are suggesting the need for cognitive analytic therapy (CAT) based approaches to meet the needs of patients, then for me, this is indicative of there being a greater need for qualified CAT psychotherapists within IAPT services, rather than increasing the range of low-intensity interventions. This may sound jarring to the seasoned low-intensity practitioner, but I will more explicitly explain the need to deepen the existing skill set before expanding on the range of intervention, in my chapters, Navigating Relationships and Therapeutic Boundaries, and Reflecting on Interpersonal Practice. Essentially, what I am saying here is that we do not need to reinvent the wheel. Absolutely, we need to constantly strive to enhance and improve outcomes for the benefit of our patients, but my argument here is that we can better do this by deepening and building on what is already established, as opposed to focusing on what is shiny and new (typically a new acronym to add to the thousands already available). Essentially, if low-intensity CBT-based psychological therapy is well matched to the patient and is appropriately assessed and delivered flexibility and adaptively focused on a here and now mild to moderate problem with anxiety or depression, coupled with developing low-intensity practitioner awareness of the therapeutic alliance, then this (for me) is more likely to lead to good outcomes and is the most stable and consistent factor in therapeutic outcomes more broadly (Wampold et al., 2002; Wampold and Imel, 2015). In my personal opinion and experience, the initial aims and scope of the low-intensity programme have become muted, and in some cases, throttled underneath targets and pressure for throughput with little attention being paid to the more problematic issues around reported access and outcome monitoring that fuels the dehumanising of distress in favour of neat and tidy problem description. Rather than embracing and nurturing the low-intensity practitioner to develop an effective working alliance conducive to psychotherapeutic change, using a simple framework of identifying thoughts and actions that maintain problems, we have ended up with workbooks positioned as the mechanism of change, with Likert scales as a determinant of success. By distracting from the humans in the room, through a focus on protocol over process, of quantitative outcomes over qualitative experience, the risk here is that the potential value and development of low-intensity practice may become entirely lost through misuse under the ever-increasing weight of limited funding and high pressure to perform.

References Ali, S., Rhodes, L., Moreea, O., McMillan, D., Gilbody, S., Leach, C., et al., 2017. How durable is the effect of low intensity CBT for depression and anxiety? Remission and relapse in a longitudinal cohort study. Behav. Res. Ther. 94, 1–8. Baigent, M., Smith, D., Battersby, M., Lawn, S., Redpath, P., McCoy, A., 2020. The Australian version of IAPT: clinical outcomes of the multi-site cohort study of NewAccess. J. Ment. Health, 1–10. Boyd, L., Baker, E., Reilly, J., 2019. Impact of a progressive stepped care approach in an improving access to psychological therapies service: an observational study. PLoS One 14 (4), e0214715. Burns, P., Kellett, S., Donohoe, G., 2016. “Stress control” as a large group psychoeducational intervention at step 2 of IAPT services: acceptability of the approach and moderators of effectiveness. Behav. Cogn. Psychother. 44 (4), 431–443. Campling, P., 2019. The industrialisation and marketisation of healthcare. In: Rizq, R., Jackson, C. (Eds.), The Industrialisation of Care: Counselling, Psychotherapy and the Impact of IAPT. PCCS Books, pp. 44–59. Clark, D., Knapp, M., Layard, R., Mayraz, G., 2007. Cost-Benefit Analysis of Psychological Therapy (No. dp0829). Centre for Economic Performance, LSE. Clark, D.M., Layard, R., Smithies, R., Richards, D.A., Suckling, R., Wright, B., 2009. Improving access to psychological therapy: initial evaluation of two UK demonstration sites. Behav. Res. Ther. 47 (11), 910–920. Clark, D.M., Canvin, L., Green, J., Layard, R., Pilling, S., Janecka, M., 2018. Transparency about the outcomes of mental health services (IAPT approach): an analysis of public data. Lancet 391 (10121), 679–686. Cooper, M., Messow, C.M., McConnachie, A., Freire, E., Elliott, R., Heard, D., et al., 2018. Patient preference as a predictor of outcomes in a pilot trial of person-centred counselling versus low-intensity cognitive behavioural therapy for persistent subthreshold and mild depression. Couns. Psychol. Q. 31 (4), 460–476.

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Cotton, E., 2019. The industrial relations of mental health. In: Rizq, R., Jackson, C. (Eds.), The Industrialisation of Care: Counselling, Psychotherapy and the Impact of IAPT. PCCS Books, pp. 209–231. Delgadillo, J., Rhodes, L., Moreea, O., McMillan, D., Gilbody, S., Leach, C., et al., 2018. Relapse and recurrence of common mental health problems after low intensity cognitive behavioural therapy: the WYLOW Longitudinal Cohort Study. Psychother. Psychosom. 87 (2), 116–117. Delgadillo, J., Ali, S., Fleck, K., Agnew, C., Southgate, A., Parkhouse, L., et al., 2022. Stratified care vs stepped care for depression: a cluster randomized clinical trial. JAMA Psychiatry 79 (2), 101–108. Fotaki, M., 2019. Throwing good money after bad: health services without care under marketised welfare. In: Rizq, R., Jackson, C. (Eds.), The Industrialisation of Care: Counselling, Psychotherapy and the Impact of IAPT. PCCS Books, pp. 60–79. Freire, E., Williams, C., Messow, C.M., Cooper, M., Elliott, R., McConnachie, A., et al., 2015. Counselling versus low-intensity cognitive behavioural therapy for persistent subthreshold and mild depression (CLICD): a pilot/feasibility randomised controlled trial. BMC Psychiatry 15 (1), 1–11. Koelen, J.A., Vonk, A., Klein, A., de Koning, L., Vonk, P., de Vet, S., Wiers, R., 2022. Man vs. machine: a meta-analysis on the added value of human support in text-based internet treatments (“e-therapy”) for mental disorders. Clin. Psychol. Rev. 96, 102179. Kroenke, K., Spitzer, R.L., Williams, J.B., 2001. The PHQ-9: validity of a brief depression severity measure. J. Gen. Intern. Med. 16 (9), 606–613. Martin, C., Iqbal, Z., Airey, N.D., Marks, L., 2022. Improving access to psychological therapies (IAPT) has potential but is not sufficient: how can it better meet the range of primary care mental health needs? Br. J. Clin. Psychol. 61 (1), 157–174. National Collaborating Centre for Mental Health, 2021. The Improving Access to Psychological Therapies Manual. Online. Available at: https://www. england.nhs.uk/wp-content/uploads/2018/06/the-iapt-manual-v5.pdf. National Institute for Health and Care Excellence, 2014. Anxiety Disorders: Quality Standard [QS53]. Online. Available at: https://www.nice.org.uk/ guidance/qs53/chapter/Quality-statement-1-Assessment-of-suspected-anxiety-disorders. National Institute for Health and Care Excellence, 2021. Depression in Adults: Treatment and Management [NG222]. Online. Available at: https://www. nice.org.uk/guidance/ng222. Powell, C.L., Lo, A.P.K., Yeung, G.T., Leung, N.T., Mak, W.W., So, S.H., et al., 2021. A pilot study on the effectiveness of low-intensity cognitive behavioural therapy (LiCBT) for common mental disorders in Hong Kong. Behav. Cogn. Psychother. 49 (6), 758–763. Rizq, R., Jackson, C., 2019. The Industrialisation of Care: Counselling, Psychotherapy and the Impact of IAPT. PCCS Books. Salkovskis, P.M., Rimes, K.A., Warwick, H.M.C., Clark, D., 2002. The Health Anxiety Inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychol. Med. 32 (5), 843–853. Scott, M.J., 2018. Improving access to psychological therapies (IAPT)—the need for radical reform. J. Health Psychol. 23 (9), 1136–1147. Scott, M.J., 2021. Ensuring that the improving access to psychological therapies (IAPT) programme does what it says on the tin. Br. J. Clin. Psychol. 60 (1), 38. Spitzer, R.L., Kroenke, K., Williams, J.B., Löwe, B., 2006. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch. Intern. Med. 166 (10), 1092–1097. Steen, S., 2019. A critical appraisal of the economic model underpinning the improving access to psychological therapies (IAPT) programme. In: Rizq, R., Jackson, C. (Eds.), The Industrialisation of Care: Counselling, Psychotherapy and the Impact of IAPT. PCCS Books, pp. 142–155. Wampold, B.E., Imel, Z.E., 2015. The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work. Routledge. Wampold, B.E., Minami, T., Baskin, T.W., Tierney, S.C., 2002. A meta-(re) analysis of the effects of cognitive therapy versus ‘other therapies’ for depression. J. Affect. Disord. 68 (2–3), 159–165.

Chapter 3

Training and competency Elizabeth Ruth University of Bradford, Bradford, United Kingdom

Low-Intensity Practitioners deliver low-level manualised interventions, why do they need post-qualification training? Private communication (May 2022)

This chapter will outline: ● ● ● ●

The underpinning model for low-intensity psychological interventions. How training might influence the practitioner’s clinical style. Styles of working that a low-intensity practitioner might adopt. How a reflective practitioner might work within the model and evidence base to provide patient-focused care. Considering

● ●

●

The role of prior experience and initial training in producing competent practitioners. How a practitioner might navigate real-life demands that are in conflict with the theoretical understanding and research evidence base for the approach. The importance of reflection in practice and practitioner self-practice, self-reflection.

Simple and agile It’s time to dig into some details. When I talk about the low-intensity psychological interventions theoretical model and clinical method, what do I mean? Nothing too fancy, that’s for sure. The joy of this approach is its simplicity; you really don’t need a doctorate to do this. Simplicity makes what we do agile, useful in a great range of circumstances, and a lot of fun. I’m going to go through what I think are the core competencies and essential training outcomes to make a good low-intensity practitioner. I’ll try to cover who tends to come into low-intensity training, who we need to come into low-intensity training, what a low-intensity practitioner needs to understand, what they need to be able to do, and how you teach that to somebody. A number of chapters in this book are intended to pose questions rather than offer solutions, and this is one such. I will describe how I have come to understand the theoretical model and clinical method that we call ‘low-intensity interventions’ and consider how this is supported in practitioner training. I will acknowledge that mine is just one way of understanding this approach; there are other ways to understand low-intensity work that I do not intend to dismiss out of hand. I will attempt to cover some ideas about how we might go about reaching shared definitions and safer implementation, using reflection in practice and self-practice self-reflection as the tools to unify learning from practice with the purely academic theoretical models and recommendations for implementation that we have in the literature. Disclaimer I will say this of everything that we write in this book: there is no such thing as a universal statement about the experience of being a low-intensity practitioner. Every service that implements this role does so in a different way. Practitioners are given different freedoms and responsibilities, the expectations about what clinical work they will undertake, the quality of support, the team culture, and the local population that they serve varies widely (you could say ‘wildly’) from one setting to another. James and I are writing from our experience and observation and we will say some things that do not agree with the experience of some low-intensity practitioners. We very much hope that Care in High Volume will be a starting point in the literature produced by low-intensity practitioners and that there will be more opportunities for practitioners to publish the learning from their unique experience in the next few years. Some of those accounts and writings will agree with our accounts and conclusions, others will not, and that is representative and healthy. Care in High Volume. https://doi.org/10.1016/B978-0-323-88492-1.00003-8 Copyright © 2023 Elsevier Inc. All rights reserved.

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What makes us different? Low-intensity psychological interventions, as an approach to offering psychological care, is very much an emerging discipline. When it comes to definitions of what is considered competent practice, and how our theoretical foundation holds together in a way that is distinct from other approaches, there are no definite answers yet. The last 15 years have been an exciting period for low-intensity interventions as the strands of previous work cohered and this new way of working was implemented in the extraordinary real-world laboratory of the IAPT programme in England as described in Chapter 1 of this book. The body of literature around this way of working is growing, as the potential of the IAPT programme and lowintensity work as an area suitable for investigation through research projects on Masters programmes and for postdoctoral researchers has become more apparent to students of psychology and psychotherapy. However, most of what is written about this way of working is written by people who have either never practised this approach with a high-volume caseload in a stepped care system in a primary care setting, or who did so for a very short period of time. The result is as if medical doctors with a research focus were writing books about how to be a nurse practitioner in a community clinic. Some of the results offer an interesting perspective; others are, frankly, a bit weird. By that I mean that it can be difficult to put what is written in the literature into practice in a live clinical setting.

Medication management For example, a review of the literature would lead someone who is not a practitioner to have an exaggerated view of the role of ‘medication management’ in low-intensity practice. Medication management is included prominently in many descriptions of low-intensity interventions, and this is likely to be a residue from the days when medical rather than psychological treatment for depression was assumed to be the most effective. Within the early idea of the role of a quasiprofessional ‘supporter’ for someone with depression, it would be assumed that the helper would have to monitor and encourage compliance with medication regimes as a priority. The fact that we ask about and advise around medication emphasises the importance of never working independently of a collaborative care system with agreed routes of communication with the patient’s GP, as a minimum. The revised NICE guidelines for the treatment of depression, published in June 2022, lists Selective Serotonin Reuptake inhibitors (the most commonly prescribed antidepressant medications) as the ninth recommended treatment option for ‘less severe’ depression and as the fourth preferred treatment for ‘more severe’ depression. We are ‘watching this space’ after the publication of the systematic review of the evidence for the serotonin theory of depression by Joanna Moncrieff and colleagues was published and made news headlines in July 2022 (Moncrieff et al., 2022). Our psychoeducation messages might have to change in light of this review, but until this learning is reflected in the national training curriculum, I will describe what we have been doing so far. It is the responsibility of a low-intensity practitioner to: ● Understand that depression and anxiety are not purely psychological, and that medication can be a powerful tool in the management of, and recovery from, these conditions, but that there is no one-size-fits-all prescription for any mental health condition. ● Know the most commonly prescribed medications for depression and anxiety and have a slightly-better-than-­ layman’s idea of how they work. ● Know the NICE recommendations for the use of medications in depression and anxiety disorders. ● Know the expected side effects from each medication: what is normal and expected, and what is not.

●

●

Understand some of the barriers that can prevent patients from taking medication as prescribed and know the consequences of abrupt discontinuation. If a patient reports that they started a medication and stopped taking it because they didn’t like the side effects, or they only remember to take it sporadically, what should you advise? (hint: it’s usually that they should speak to their GP or pharmacist). Know which medications can be a barrier to a psychological treatment. For example, the mechanism that makes Graded Exposure Therapy (the behavioural intervention that we usually offer for agoraphobia, panic, specific phobia, and OCD) can’t work if the patient uses benzodiazepines or beta blockers to quell their anxiety when it is triggered.

We have to know which medications are prescribed for more severe, complex, and enduring mental health conditions because a patient might not volunteer information about other mental health diagnoses. Record sharing between teams within the NHS can be problematic so a low-intensity practitioner might not (in fact, probably won’t) have access to records of previous mental healthcare; recognising the role of a medication that can prompt questions about other mental health conditions that might mean that the patient would be unlikely to derive much benefit from a short and structured psychological intervention in a primary care stepped care service.

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The conversation about medication in a low-intensity appointment will often go something like this: Low-intensity practitioner: Can I check if you’re taking any prescribed medication for your [insert common mental health problem]? Patient: I don’t really like the idea of tablets; I don’t want to get addicted to anything. Practitioner: Some people can find a medication very helpful but it doesn’t suit everyone. I’ll just reassure you that most modern medications for [depression or anxiety] aren’t habit forming or addictive. For [insert common mental health problem], the recommendation is that [practitioner here inserts short description of NICE recommendation regarding medication for the presenting common mental health problem] [often add]. For symptoms like yours, the evidence is that talking therapy can be as effective as medication for a lot of people but tablets and talking therapy can work well together. There is always the option to talk to the GP about what they recommend, if that’s useful. Patient: OK, thanks. The practitioner reviews if there have been any changes to medication use at each subsequent session. Or Low-intensity practitioner: Can I check if you’re taking any prescribed medication for your [insert common mental health problem]? Patient: I’ve got some tablets but I think that I’ve been feeling worse since I started to take them. Practitioner: I’m sorry to hear that you’ve had some unwanted effects. Can you tell me more about that? Patient: I’ve noticed I’m feeling sick and shaky all of the time, a bit dizzy, and my mood definitely isn’t getting any better. Practitioner: It sounds like it’s been rough for you. I’m just thinking that some of the most common medications can make you feel a bit worse for about 4 to 6 weeks when you start to

take them, but it will often settle down. Do you know what your medication is called and how much is prescribed? Patient: Urgh, Flucolazine? Florine? [or some other attempt to remember the name of a selective serotonin reuptake inhibitor] Sorry, I can’t remember what it’s called. Practitioner: OK, thanks for that. Could it be Fluoxetine that you’re on? Patient: Yeah! Practitioner: How long have you had it? Patient: About 3 weeks. Practitioner [who does a risk and safety review with all patients at every session and has established that there is no increased risk of suicide or self-harm and that the patient would know where to get help if this changed]: And you’re feeling that there are some side effects. Has your GP planned a review with you? Patient: No, they didn’t mention anything like that. Practitioner: It is recommended that the prescribing doctor should see how things are going after you’ve been on one of these medications for a few weeks. The doctors all manage that a bit differently. How would you feel about booking an appointment in the next week or two to talk to them about side effects and how the medication is working? Patient: Yeah, I can do that. Practitioner: Is there anything else you’d like to ask or check about the tablets? Patent: No, thanks. I’ll see how it goes and talk to the doctor again soon. Practitioner: Thanks for filling me in about your tablets. If it’s OK with you, I’d like to see how that’s going next time we talk, but it sounds like you’re doing everything right and hopefully the early effects will settle, and you’ll start to feel the benefit soon. [the appointment progresses]. And that’s about it for medication management, despite the emphasis placed on this ‘intervention’ in some of the literature that supports implementation and training for low-Intensity interventions.

What is in an ‘intervention’? One of the roots of some of the confusions around what constitutes ‘low-intensity interventions’ is how we define the word ‘intervention’. In some of the literature, a low-intensity ‘intervention’ is a written self-help guide that is intended to be either read and used independently by a patient or accessed with support from a clinical helper who could be a Psychological Wellbeing Practitioner or other qualified guide to the material. Although there is good evidence for pure bibliotherapy and simple guided self-help, as described in Chapter 1 of this book, this does not sufficiently describe what a competent lowintensity practitioner can offer. The understanding that ‘low-intensity interventions’ is synonymous with ‘supported bibliotherapy’ derives from a purely academic understanding of low-intensity practice. This understanding of low-intensity interventions doesn’t draw on learning from a process of reflection on clinical practice but assumes that learning from controlled clinical trials and reviews of literature is adequate to describe what is happening, and what should happen, in a live clinical setting. The literature on reflective practice is a helpful counterbalance here, with a model that enables us to balance purely academic notions with learning from the unpredictable and varied encounters of live practice (Schon, 1983; Rolfe, 2002). In teaching on a graduate and postgraduate certificate programme that provides a qualification for low-intensity practice, we use the word ‘intervention’ to describe a specific therapeutic strategy based on a defined and logical theory. An intervention can constitute a simple course of treatment which is tailored to reverse the cycle of symptoms that maintains a

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common mental health problem or interventions might be combined in a course of treatment to enable the patient to move away from the presenting problem and towards their goal for treatment. This second interpretation is what we will apply to the word ‘intervention’ in this chapter.

Self-help material You will come across some published, even peer reviewed, literature that claims that self-help material does all of the heavy lifting in low-intensity psychological interventions. I … disagree. Did you see how I didn’t put a swear word into that response? Quite proud of myself for that. I was about to say that there isn’t space to go into the in-and-outs of this here, but if not in a book, then where? The role of self-help material definitely hasn’t been properly addressed in research papers or blog posts so far. What is self-help material? I would consider any written, audio-visual, or computerised resource that contains accurate information about depression or an anxiety disorder and evidence-based instructions on what you can do to manage the symptoms of those conditions to be self-help material. I have already acknowledged that there is plenty of evidence that self-help is an effective stand-alone intervention for some people who just need a nudge in the right direction to get better. I haven’t dug into this too deeply but we all know at least one person, who prefers to manage their problems independently, does their own research and tries to work things out for themselves. Good quality self-help resources are freely available all over the internet and in most public libraries in the United Kingdom. A lot of people with mild-moderate symptoms of depression, stress, and anxiety will find and access those resources before they think about going to their GP or an IAPTtype service for help. So, by the time someone is talking to a low-intensity practitioner, it’s likely that they are at the point when, for whatever combination of reasons, a self-help intervention isn’t going to be enough on its own. One of the most common criticisms of low-intensity practitioners is that we ‘just give out workbooks’ (I found that one on Reddit, but you’ll hear it in other places as well). Because Psychological Wellbeing Practitioners are usually the first point of contact with an IAPT team, many people have this impression of the whole IAPT programme, not just the lowintensity practitioners who provide the initial assessment. It’s true that all of the current definitions of low-intensity interventions emphasise the important role of self-help material, and it is correct that they should do so. Low-intensity practitioners have very limited time with their patients and the efficacy of low-intensity psychological interventions relies on the patient being able to learn information that will help them to understand their difficulties and learn specific ideas that might help to relieve those difficulties. If some of that work can be done outside of the appointment time, we can do a lot more good much more quickly than if the whole course of treatment relies on what we can communicate, and what the patient can absorb, in their limited session time. As well as the time saving function of self-help material, it can be an effective way to make sure that the patient is making informed treatment decisions and has a resource to call on that does not strengthen their reliance on the practitioner. Our aim is always to equip the patient with what they need to help themselves and reduce the patient’s perception of our (perceived!) superior expert power as quickly as possible. Whilst self-help material is a great supportive resource for both the practitioner and the patient who are engaged in a piece of work together, there should never arise a situation where the workbook is doing the work of the practitioner. ‘Today we are looking at pages 4–8 in your workbook and next week we will cover 20–24, after you have read pages 9–19 as homework’ is not great low-intensity practice. What is considered to be adequate and good-quality self-help material is still up for debate. It’s been the wild west for many years, with Psychological Wellbeing Practitioners gleaning material wherever they could find it for free. Sometimes the choice of workbooks and worksheets is guided by a supervisor or a more experienced practitioner, but very often, it has come down to the personal preference of the individual practitioner. More recently, some IAPT teams have started to produce their own self-help material so that what is shared with patients can be standardised across the team. A matrix for the evaluation of the use of self-help material in IAPT services has been available for several years and an evaluation of this tool was published in 2022 (Farrand et al., 2022). Whilst this framework can be useful to get practitioners thinking about what to look for in the material that they share with patients, there are limitations to it. The paper insists on ‘singlestrand’ material and strongly leans towards the use of larger workbooks that contain a great amount of detail including case vignettes, background theory, goal setting, risk management, and relapse prevention as well as all of the possible steps in the intervention. However, in practice, many patients welcome a single sheet of information that is relevant to the work completed in an appointment, or a single-page worksheet to guide a between-session activity. There is also an implication in the paper that someone who can’t read or write, or who reads and writes in a language in which self-help material is not readily available, or who declines to make use of written material during their course of treatment from preference alone, cannot benefit from a low-intensity intervention, and this simply isn’t the case.

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Sources of self help The ‘big ones’, that is, the most commonly used and reasonably good-quality self-help resources in circulation as of writing are as follows: Mood Juice is the library of self-help information available from NHS Scotland, hosted by their ‘NHS Inform’ website. These guides cover information about common mental health problems and there is a series of interactive self-help guides that can be worked through independently on the website. CEDAR These comprehensive workbooks from the University of Exeter are often held up as the gold standard of self-help material. They are a great resource and when patients are able to engage with large volumes of written information can be offered as stand-alone information for patients to engage with when treatment has finished, or selected pages can be used to supplement work with a practitioner. The University of East Anglia offers a selection of therapy worksheets for low-intensity practitioners on their ‘IAPT and CBT Resources’ web page. These are visually appealing and accessible brief resources with accurate information about the treatment strategies but are designed to be practitioner-­ supported and would not make much sense to most people without the context of a supported treatment intervention. TalkPlus is the first of what seems likely to be many developments of suites of self-help resources by IAPT teams who don’t find the materials that they want their practitioners to use available elsewhere. I mention these here as an example that is used widely in the region where I work. More classic resources that are still occasionally in use are: GetSelfHelp is an extraordinary website hosting hundreds of free to access therapy resources. For years, it has been the Psychological Wellbeing Practitioner’s go-to source of diary templates and easy-to-print five areas models. However, the site contents are not always in line with the limitations of lowintensity work. It was too easy for practitioners to think that everything on the site is suitable for implementation in a lowintensity clinic, ignoring the fact that the resources are used by high-intensity CBT therapists (Tallon et  al., 2019) and the information and techniques demonstrate principles and strategies from other approaches like DBT, as well as offering some nonspecific information and ideas that wouldn’t necessarily get past a governance process in an NHS team. We have got a lot of reasons to be grateful to the curators of this site but have to approach with caution. SHARP Self-Help Access in Routine Primary Care or ‘SHARP’ (https://www.primarycare-selfhelp.co.uk/) was ­ developed to

provide easy access to good-quality self-help material in primary care settings. It is an online resource that was designed to be easy to navigate and print. I used SHARP frequently in my early PWP career and it is still a helpful and well-rounded resource. The Centre for Clinical Interventions workbooks are a resource available on a website hosted by the Government of Western Australia. These are comprehensive courses of reading but, like other resources on this list, old in comparison to how we have developed as an approach, and they tend to drift towards high-intensity CBT concepts and techniques. Although not perfectly suited to low-intensity work, they have been a fantastic resource and I have often wondered if we bewildered the website admins with the thousands of hits the site must have had from England over the years. Chris Williams Overcoming Depression: a Five Areas Approach (Williams, 2001) and Overcoming Anxiety (Williams, 2003) Chapters from these books were available as stand-alone self-help workbooks in many services in the first decade of the millennium, including pre-IAPT services that delivered guided self-help. My first two employers in my low-intensity career kept huge stockpiles of these chapters in floor-to-ceiling cabinets to hand out to patients. These still occasionally appeal to patients who like very thorough and more academic guides to the ideas and strategies that we support. Students tend to find them wordy and too academic when we use them in a teaching exercise on critical comparison of resources (I’ll admit that I include them out of sentiment as much as anything, I had some good times with those workbooks in the olden days!). The latest iteration of these materials is available through the online resource ‘living life to the full’ (https://llttf.com/) which some IAPT services have used as their computerised CBT offer for the last few years. None of these are perfect; none of them will suit every patient either in how the content is written or in how it is presented. None of them would score a perfect score on the evaluation tool that I mentioned above (Farrand et al., 2022). When I use a CEDAR guide, for example, I will often see a patient look dismayed by how long it is, or how the information is formatted, and I’ll joke to soothe their anxiety; ‘these are written by academics who really like the sound of their own voice, but it’s good information to have’. When I use a single sheet of information or a worksheet, I always negotiate where it is going to be stored ‘you don’t want to loose it in the bottom of your handbag and forget it…’.

Not everybody reads… Of course, there are barriers to the use of self-help material. Some of our patients ● ● ● ● ●

can’t read haven’t got access to the internet have demanding lives that leave no time or privacy for reading speak and read languages in which there is no written self-help resources available or, simply don’t want to read self-help sheets or booklets

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There is also a problem in that many workbooks and self-help resources use fictional case vignettes to illustrate the ideas, but some patients won’t see themselves or the lives that they live represented in those vignettes and that can be a barrier to taking the ideas and information on board. In 2021, Liz Kell and Allan Laville produced a series of case vignettes for the British Psychological Society that are designed to support practitioner training and represent and celebrate the diversity in the communities that low-intensity practitioners serve (Kell and Laville, 2021). We can use this resource in teaching but making widely available self-help material truly inclusive is a challenge with no easy answers. If no suitable self-help material is available for a patient, does it mean that we can’t deliver a low-intensity psychological intervention? Absolutely not, because the self-help material that we use supports and supplements our interventions, it isn’t the intervention.

Where book and relationship meet A reoccurring criticism of low-intensity practitioners from patients and other psychological professionals has been that we rely on self-help material to the exclusion of human to human communication, or that our sessions are so structured that they are robotic and superficial with no genuine interpersonal connection. That hadn’t ever been my experience of this work or low-intensity practitioners, but it’s clear that there are some philosophical differences between training providers when it comes to defining the heart of our work. Are we technicians who facilitate access to ‘healthcare technologies’, or are we psychological practitioners who engage in a (structured, competency-limited) interpersonal alliance in order to bring about effective change? James’ Chapters 8 and 9 on the therapeutic relationship and interpersonal elements in low-intensity work lay out what the authors of this book think about that.

Stay in your shipping lane If low-intensity interventions are truly distinct and not a ‘lite’ version of CBT, or, as can sometimes happen with inadequate supervision, a pseudo form of counselling, we need to understand what principles steer the work of the practitioners who deliver the approach and define what would constitute therapeutic ‘drift’ beyond the boundaries of the approach. Members of the low-intensity psychological interventions teaching team at the University of Sheffield describe the importance of staying in our lane clinically but expand this to say that we work in a broad shipping lane, not a narrow cycle lane. There is room for movement within the boundaries of our approach, room for individual style, and, more importantly, room to do things differently in response to what our patients need in light of their abilities, character, and circumstances.

A unifying model The 2015 review of the national curriculum for the education of Psychological Wellbeing Practitioners by University College London introduced a specific recognition of the importance of behaviour change models in low-intensity psychological work. In particular, the review highlighted that for the ‘self-help’ element of the approach to be properly supported, the use of behaviour change models and motivational techniques was essential. The COM-B model (Michie et al., 2011) was proposed as the most suitable and comprehensive behaviour change model available that could integrate easily into low-intensity practice and become a unifying principle that held the expanding range of techniques and interventions together. Marrying that review with reflection on clinical practice, it is possible to arrive at an understanding of low-intensity psychological interventions as a problem-solving behaviour change approach that is defined by the COM-B model and which integrates theory and techniques from behavioural theory, cognitive theory, motivational interviewing, problemsolving, behavioural activation, and health psychology. All delivered by practitioners who are expert in the ‘common factor skills’ that, ultimately, derive from Carl Roger’s humanistic counselling approach. In the future, it seems likely that the mindfulness and the process-based ‘third wave’ of Cognitive Behavioural Therapy will find its way into low-intensity practice as principles from acceptance and commitment therapy, compassion-focused therapy, and mindfulness-based cognitive therapy are adopted to overcome barriers to change during the implementation of the traditional low-intensity interventions.

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Principles from process It was my great privilege to attend (remotely) a workshop ‘Moving beyond Therapy Manuals: An Introduction to ProcessBased CBT’ delivered by Professor Stefan Hofmann at the European Association for Behavioural and Cognitive Therapies summer conference in September 2021. I am not a CBT therapist and low-intensity psychological interventions are not CBT or process-based therapy; the finer points of Dr. Hofmann’s teaching were beyond the scope of what I practice with patients and teach to my students, but the principles that he outlined resonated deeply with my understanding of the lowintensity approach. My takeaways from that workshop that describes my understanding of low-intensity psychological practice were as follows: ● An emphasis on moving away from formal diagnostic criteria. I have written a note in quote marks: a caution to

●

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practitioners not to ‘pathologise normality by arbitrary cutpoints’ in the DSM and ICD diagnostic manuals. The words ‘You need to know the problem, not the diagnosis’ make me punch the air ‘yes!’ This is what we do as LI practitioners. That a ‘radically ideographic approach’ is needed; instead of a ‘protocols for syndrome’ approach—that the ‘manualised’ approach to low-intensity interventions described later in this chapter would advocate—we should use ‘core strategies to build the treatment that the patient needs’. Training should be two-pronged: covering how to deliver specific therapeutic strategies and how these strategies can be combined. You will see below that this is congruent with how I was trained, how I have practised and supervised, and how I now teach low-intensity psychological interventions.

Step-by-step It is too easy to provide an education in low-intensity psychological interventions that fails to impart any sense of the unifying theory that underpins and makes coherent the work that we do. This is partly because, in many people’s understanding, we haven’t got one. We could propose that the model would guide us to: 1. Accurately identify a problem In the fantastic CBT for Mild to Moderate Depression and Anxiety: A guide to low intensity interventions (Hughes et al., 2014), the authors describe the primary importance of collaborative assessment which ‘requires a partnership of equals with one partner aware of clinical conditions, their nature and what maintains them and the other aware of their own illness and all it brings to their life’. 2. Agree a goal The goal is one that the patient wants to achieve through the course of treatment. The goal has to be behavioural (that is, measurable, achievable, and realistic) and valuable to the patient. A session-by-session reminder of the starting problem and the goal for treatment can help to build motivation for change and reinforce the helpful changes that do take place between sessions. 3. The application of a simple formulation A formulation to understand how the components of the problem affect each other to maintain the problem. Providing a good, motivating rationale for the change strategy that you are implementing is much easier when the patient shares your understanding of how their problem works. 4. Use of the COM-B model Throughout assessment and treatment, the practitioner keeps the model in mind; it is used to identify barriers between the patient and their goal and guides, the questions that are asked, and the volume and pace of information that is provided. The ongoing COM-B assessment informs the balance of common and specific factor skills in a session. 5. Implement the right intervention(s) or strategy(ies) The problem descriptor, goal, formulation, and COM-B assessment are used to inform the selection of the strategies that will best enable the patient to break the maintenance cycle, therefore moving away from the problem and towards their goal.

On teaching new practitioners There is a lot of information to cover during the traditional 1-year training programme that qualifies us for low-intensity psychological practice. Too much information, really, to expect students to absorb and understand it on a deeper level than the retention of didactic knowledge. Students leave the programme in possession of the information that they need to know to practice safely, but it can be months or years of practice before there is a ‘click’ of understanding about how

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and why it should all fit together. This can be mitigated to some extent by embedding reflective practice and self-practice, self-­reflection (Bennett-Levy et al., 2015; Haarhoff and Thwaites, 2016) within the training programme, and having practitioners in teaching roles on the courses. These teachers can use the learning from their own low-intensity psychological practice to build bridges between the theory taught on the course and the reality of a live clinical setting. In my Chapter 11 on the professional identity of low-intensity practitioners, I provide a bullet list of what I think are the defining features of low-intensity psychological interventions, I won’t repeat that here but I will say, quickly, that this is a brief problem-solving behaviour-change approach and the COM-B behaviour-change model is what holds it all together. Clinical skills practice The national curriculum for the training of both the Psychological Wellbeing Practitioners and the standards for the accreditation of training programmes for Psychological Wellbeing Practitioners in the IAPT programme emphasise the importance of clinical practice as part of the training year. There is mandated and dedicated time during the teaching days when students practice how to implement the theoretical learning in a conversation. They do this together in skills practice groups, with intensive coaching from a member of the teaching team. In a small group ‘clinical skills practice’ on the programme that I lead, we emphasise the benefit of a safe space to practice with peers where students can make mistakes without consequences. It would be unrealistic to expect students to participate in a lecture on a skill set in the morning and then absorb the learning and practice it flawlessly by the afternoon. Formulating a form of words that you might use to describe an intervention to a patient is not as instinctive as you might assume. I encourage my students to practice describing the interventions to a child. To badly paraphrase the quote widely attributed to Einstein: If you can explain something to a 10-year-old in a way that makes sense to them, you probably understand it pretty well.

Hearing about the stages of an intervention in a lecture and then working out how you are supposed to facilitate a conversation that guides another person through that same information and towards behaviour change is a process fraught with doubt and anxiety, especially when you are expected to perform this skill publicly. It is an effective but often uncomfortable teaching strategy that requires expert facilitation from the teaching team. We refuse to provide scripts or suggested forms of words for these exercises; effective clinical work requires congruence—the practitioner must be able to be truly themselves and work from a true understanding of the intervention that they are delivering. A script or using somebody else’s form of words would threaten the development of an effective rapport between patient and practitioner. We provide the students with time to think about what they have been taught, and fictional case examples to work with, whilst requiring every student to demonstrate their practice so that the teacher and peers in the group can observe and provide feedback. There is some urgency to this theory-to-practice transition, our students move straight into live clinical practice in their IAPT service practice placements; low-intensity trainees must put the ideas that they are taught into practice straight away.

Training cultures As of writing in 2022, there are 37 accredited Psychological Wellbeing Practitioner training courses that offer the traditional graduate or postgraduate certificate across 19 educational institutions. In addition, four training providers offer an apprenticeship programme, but this number is growing rapidly as the benefits of the apprentice route to qualification are recognised. Each training institution offers a different learning culture and environment. Every course leader and teacher will draw on their own work and life experience, their own understanding of the theory and methods of low-intensity interventions, to shape the material and deliver an understanding of the elements on the national curriculum. These different training cultures can produce very different types of practitioner.

A deeper dive The limitations of this chapter mean that we are giving a superficial and descriptive account of some of the aspects of low-­intensity training from a limited perspective. Some recommendations for further reading and “watch this space” hints are provided here for people who want to explore the experience and effect of practitioner training in the IAPT context more deeply. 1. Dr. Rebecca Hutton’s thesis, “The Making of Psychological Therapists: Towards a Psychosocial Understanding of IAPT Training, Culture and Practices” (Hutten, 2018) provides a multifaceted and eye-opening exploration of the ­experience of training in the IAPT context. Dr. Hutton’s descriptions

and conclusions closely correlate with the experience of the authors and our messages in this book. 2. For some insight into how elements of low-intensity training programmes are designed and the reasoning behind one of the teaching and learning strategies, Joel Owen’s, 2020 article “The use of Practice-Based Learning Days on Psychological Wellbeing Practitioner training programmes: A Self-Determination Theory perspective” makes for interesting reading. 3. The same author led on the 2022 article “Stress, resilience and coping in Psychological Wellbeing Practitioner ­trainees: a mixed-methods study” (Owen et al., 2022) which made

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for an interesting reading as a new course director and provides a practical and helpful insight into sources and responses to stress amongst low-intensity practitioner trainees. 4. The 2019 article “An evaluation of the transition from BAME community mental health worker to IAPT low intensity Psychological Wellbeing Practitioner” (Hakim et al., 2019) by former PWP Naheem Hakim and colleagues is not focused specifically on the experience of training but is a fascinating insight into the interaction of minoritised cultural and racial identity with the experience of entering and working in IAPT services. 5. For “watch this space,” I recommend that anyone interested in low-intensity practitioner training keeps an eye

on the work of Clinical Psychologist, Dr. Michelle Wilson, from University College London. In collaboration with the University’s Psychological Wellbeing Practitioner (PWP) training programme, Dr. Wilson is piloting and evaluating a self-compassion workshop that is integrated into the core curriculum for trainee mental health professionals, including PWPs. This builds from her earlier research which had identified high levels of self-criticism and low levels of self-compassion amongst both PWP and clinical psychology trainees within the country. This is an exciting and very practical development, and I will briefly say more about this in Chapter 7 on low-intensity practitioner wellbeing.

Manualised training Some programmes emphasise a ‘manualised’ understanding of the interventions, in line with that idea of the written selfhelp material as the intervention and the role of the practitioner to guide the patient through a workbook or programme of reading. This is appropriate when practitioners are supporting a course of computerised CBT but not when they are working 1:1 with an individual. There are practitioners who have been taught that the same content should be covered at the same session with every patient who they work with, and these practitioners become anxious when the patient is not able to progress through the steps of an intervention at the “right” predetermined pace. As well as producing anxious practitioners, this way of working might feel superficial or generic to patients. It allows little room for the application of the essential common factor skills that facilitate engagement and a sense that the patient’s difficulties have been accurately heard and understood.

Principles to practice Other programmes put an emphasis on working with the individual to provide the education in the principles and techniques that target that person’s barriers to helpful change, using written material as a supplement to support the work that takes place in the meetings between practitioner and patient. Although this approach enables practitioners to be responsive to the individual person whom they are working with, the risk for these practitioners is a drift away from matching the right intervention to the presenting problem.

Celebrating grace A chapter about training has to include the essential characteristics that make a good psychological practitioner. The majority of the people who attend our training programmes already have, or have the capacity to acquire the essential interpersonal competence and didactic knowledge necessary to deliver an effective psychological intervention. What is harder to teach are the values and attitudes required to provide truly equitable services. Equitable means that patients are not given identical services but that resources are distributed fairly to meet the different needs of service users. One person might face more barriers to care than another and need more time, thought or effort; this is provided so that everyone can access the service. A genuine engagement with and commitment to inclusive and equitable practice creates safe practitioners for a whole community, and can provoke the energy needed to take action for change where discrimination is encountered or service provision is not equitable. Many of our students have not deliberately engaged with the work of antidiscriminatory practice before training. Anyone who has been on the journey of examining their own unconscious biases, identity, privilege, and power learned to recognise and celebrate the differences between people who hold a variety of intersecting identities will know that this work can be tiring and not always comfortable, but it is a necessary process. There are a number of ways to cover the values of recovery-informed antidiscriminatory practice during training. After a prompt from Taf Kunorubwe of the University of South Wales, we introduced the ‘social graces’ (Burnham, 1993) to our students. Students are encouraged to describe their graces (see below) and how these aspects of their identity intersect (Crenshaw, 1989). They can share this picture of themselves and the story of who they are with each other, and then are prompted to ask each other about their areas of difference.

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Although gentle—no student is required to disclose anything that they do not wish to share with their peers—this exercise can prompt discomfort as students confront their anxiety about making mistakes, and defend themselves against being perceived to have biases that might lead to discriminatory behaviour. Facilitating this exercise highlights how necessary it is for all practitioners to continue to actively pursue the courageous self-knowledge that will enable them to compensate for the biases that we all have, and to become actively antidiscriminatory not just in practice but in fact.

The social graces (Birdsey and Kustner, 2021) G: Gender, Gender Identity, Geography, Generation R: Race, Religion A: Age, Ability, Appearance C: Class, Culture, Caste E: Education, Ethnicity, Economics S: Spirituality, Sexuality, Sexual Orientation

Assessing competence How trainee competence is assessed during the initial weeks and months of the introduction to this approach is, obviously, highly significant. Trainee practitioners need to know what is ‘good enough’ practice and course teams and the services who employ trainees need to evaluate fitness to practice. There are guidelines on how competence should be assessed and several ‘competency measures’ are available, all based on the Reach Out guide (Richards and Whyte, 2008/2011) that has been the ‘Bible’ of low-intensity practice since the start of the IAPT programme. Later, in this chapter, I describe some of the different practice styles that I have observed amongst low-intensity practitioners. I suggest that the culture in which trainees’ skills are developed and the way that their competency is assessed will combine with who they are as a person to determine the type of practice that they adopt. A recent validated competency measure (Kellett et al., 2020) with good interrater reliability allows room for clinical judgement by the assessor as they measure how competent the practitioner is in using the common and specific factor skills to deliver a low-intensity assessment or intervention. Some competency measures are more rigid, and trainees can fail to achieve a ‘good enough’ rating if they do not follow a specific order in the content of the session and, sometimes, if they do not follow a specific form of words. There is a caution here for training programmes; in a demanding and stressful training year, we don’t need to add to the fears that our trainees experience. Nurturing a students’ ability to be themselves whilst adhering to the structure and methods that define this approach is more difficult for a teaching team than training students to conform to rigid protocols but is likely to have long-term benefits for practitioner wellbeing, retention, and the quality of the work that is produced.

Former PWP, CBT Therapist and current clinical psychology trainee Jason White provided this quote in a personal correspondence that succinctly described what we have seen happening on some training programmes. …The quality of the training varies greatly between each course. I believe that all courses need a certain level of standardisation to ensure that there is an equal footing amongst PWPs. I believe that some courses need to move away from simply memorising a script and instead focus on developing the confidence and competencies of clinicians. Help them learn the proper way to assess without relying on a template, help them manage complexities in their sessions and teach them how to reflect and, make sure there is a thorough understanding of the different diagnostic disorders and theoretical underpinnings that envelop the work they do.

It would be tempting to look for regional variations in training cultures—England has an infamous cultural North-South divide that might map onto this issue—but that would be false. The culture, content, and style of training are unique to the course team that is delivering it. To achieve the accreditation standards that are required by the British Psychological Society, we all have to adhere to the national curriculum for the training of Psychological Wellbeing Practitioners. How we implement the requirements of the curriculum and the accreditation standards is as varied as the implementation of the IAPT programme in different teams and is very much a matter of local leadership. My own programme and the programmes that I have trained in and worked most closely alongside emphasise a good understanding of the theory that underpins the interventions, the importance of taking the time to get an accurate and

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shared problem descriptor with the patient and providing multi-strand interventions that are matched to the patient, their definition of the problem, and their treatment goal. This way of working does not lend itself to scripted sessions but relies on the development of sound clinical judgement from reflective practice.

SPSR There has been a welcome and growing trend to implement self-practice self-reflection programmes in low-intensity practitioner training. During my training as a low-intensity practitioner in 2010, we were encouraged to have a go at the interventions ourselves, but this was not part of a formal self-practice self-reflection programme. The experience of keeping a behavioural activation baseline diary and practicing graded exposure therapy on myself did cement the value that I hold for our work. It also meant that when I was discussing in-between session practice with my patients, I could say, authentically, ‘they made us do this on my training…’ and offer reflections from my own experience to normalise the experience and barriers that my patients encountered when they had a go with the change methods. As a course leader who was lucky to have an initiation into education as a teacher on the excellent IAPT training programme at the University of Sheffield, I have copied the longer-established programme and bedded SPSR into the Psychological Wellbeing Practitioner training programme at the University of Bradford. Our students all work through an SPSR workbook at the same pace, with facilitated reflective spaces after each exercise. The introductory page of our workbook says: Reflective practice is an essential metacompetence that every psychological practitioner should develop. Self-Practice/SelfReflection is a strategy that gives practitioners of CBT-based approaches opportunities to learn the specific skills of the approach ‘from the inside out’ (Thwaites et al., 2015) and reflect on the implications of the self-practice exercise as a practitioner, supervisee, and human being. There is consistent evidence that this approach enhances understanding of CBT-based interventions, therapist skills and confidence, and belief in the value of the interventions for both novice and experienced clinicians. As with any technique, participants; level of engagement is key to the benefit they experience, i.e., the more you put in, the more you get out.

Single-strand versus multi-strand A flick through a recently published clinical manual for low-intensity CBT practitioners (Farrand, 2020)—a comprehensive guide to low-intensity interventions—cautions against ‘therapeutic drift’ in low-intensity work. In that volume, ‘drift’ is described as multi-strand working. The idea of single-strand work as a defining criteria for low-intensity psychological interventions appears in several publications but is the product of a single school of thought and is not generally accepted as best practice. I did not encounter the idea of ‘single-strand’ interventions until I had been in practice for 5 or 6 years and it struck me as a restrictive and exclusionary way of working. What we now have to call ‘multi-strand’ interventions are what I have always thought of as ‘best and normal practice’. What is meant by the phrase ‘single-strand’ work? This phrase describes a way of working that would limit the practitioner and patient to the use of a single low-intensity strategy or intervention in a course of treatment. So, a patient could either complete a course of appointments that worked through the stages of behavioural activation or problem-solving or cognitive restructuring or graded exposure or worry postponement or sleep hygiene and retraining. If barriers to change arose during the intervention, it would not be permissible to use another strategy or intervention to overcome that barrier. If one part of the presenting problem was resolved quickly, it would not be permissible to support change in another part of the presenting problem with a different intervention. Some IAPT teams that place a priority on practitioner wellbeing encourage single-strand work in order to protect their low-intensity practitioners from being overwhelmed with complex work that is beyond their remit. Other services insist on single-strand work in order to protect their reported service outcomes. When every patient who enters the IAPT service is required to access a low-intensity treatment intervention before they can progress to other types of therapy, single-strand work essentially creates discriminatory exclusion criteria that limits access to the IAPT service to people with very straightforward presenting difficulties. I would argue that if the entry into low-intensity treatment appointments is managed effectively and patients are not required to engage with a low-intensity treatment when they have got complex presenting problems that require a different treatment type, then single-strand work is not a realistic or helpful way to use the limited time that a patient has with a practitioner—it is essential that the practitioner has access to the full range of interventions and strategies in order to support the patient to overcome any barriers that arise in progress towards their goal.

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Two options for multi-strand work A course of treatment using low-intensity interventions can consist of just one intervention or strategy when that is sufficient to meet the patient’s needs. There are two reasons why this is not sufficient for every person who could benefit from low-intensity psychological interventions. 1. When we are supporting a person to learn and use an intervention or strategy, barriers often arise. This can be in the form of life events during treatment, or factors within the person themselves. We continuously use the COM-B model to assess barriers to helpful change. When a barrier is identified, sometimes we have to introduce elements from an additional intervention to help the patient to overcome that barrier and progress with the primary intervention or strategy. For example, in the treatment for depression, insomnia might be a barrier to helpful behaviour change (it’s more difficult to plan, problem-solve, and enjoy activity when you are sleep deprived!) so we would introduce sleep hygiene to support behavioural activation. 2. One intervention might be completed but there might be residual symptoms that the first treatment intervention was not sufficient to address, or the patient might have originally presented with a combination of problems that prevented them from achieving their treatment goal. In fact, most people present at an assessment with either a combination of anxiety disorders or a combination of depression and anxiety. You can’t work on all of the parts of a complex problem at once, but we can tease out strands and work on them one at a time. For example, a patient with panic and low mood might benefit from cognitive restructuring to reduce the impact of the catastrophic misinterpretation of physical symptoms that maintains panic disorder (with a potential secondary benefit that they have also learned how to manage any negative automatic thoughts that impact on emotion and behaviour in a way that maintains depression). Once that strategy is learned, it might be appropriate to initiate graded exposure therapy which is focused on reintroducing planned valued or routine activity with a combined positive effect on panic and low mood.

Implications for ethical implementation Training programmes will outline the steps of a CBT-based low-intensity intervention. The mechanisms that make the intervention effective are acknowledged, and there will be some discussion about how the intervention might work, or not work, for patients with different presenting problems, life circumstances, and intersectional identities. The low-intensity approach, as we have described it in this chapter, is useful for the range of common mental health problems: depression, panic, generalised anxiety, some phobias, as well as for supporting general ‘wellbeing’ and stress management (although ‘stress’ is a controversial problem descriptor); that is, low-intensity interventions are a suitable vehicle to deliver key health messages around the behaviours that support good physical, social, and mental health and resilience. A well trained low-intensity practitioner can deliver effective psychoeducation that is the starting point of understanding how to make sense of the health difficulties that most people will encounter at some point in their lives and can be a good starting point for the treatment of OCD. Increasingly, low-intensity practitioners are asked to work with patients with complex anxiety disorders where there is little evidence of effectiveness; health anxiety, enduring OCD, lasting responses to traumatic life events, and long-standing social anxiety disorder. This is often because the low-intensity practitioner is easily available and high-intensity therapists with training in the evidence-based protocols are scarce. Sufficient training to work effectively with those complex difficulties takes years, and costs a substantial amount of money, so there are insufficient resources to offer the evidence-based treatment for more complex anxiety presentations in the volume that is needed. This is not to say that a patient with a complex anxiety disorder with severe symptoms could not benefit from the psychological self-care strategies that a low-intensity practitioner can facilitate. What it means is that low-intensity interventions should not be offered instead of the right level of care, and access to the appropriate level of care and the evidencebased approach for the presenting problem should not be conditional on low-intensity treatment first.

Complexity and burnout A low-intensity practitioner who is delivering the best that this approach can offer has to be fully engaged with their patients, working in a person-centred way that is adapted to the identity and life experience of the person who they are working with. They have to be curious, creative, reflective, able to make good clinical judgements, and be transparent and open to critical feedback on how they practise. None of these essential requirements is possible when a practitioner is burntout, and burnout is a significant occupational risk for low-intensity practitioners. In Chapter 7, we discuss the personal cost of high-volume work in a target-driven system in more detail. In this chapter, we have described the potential that this approach can offer and will simply point out that many services do not give their low-intensity practitioners the right environment in which they could offer this full potential.

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High-volume caseloads of simple common mental health disorders where the majority of the severity is towards the milder end are realistic. High-volume caseloads of complex anxiety disorders and severe and complex depression linked to posttraumatic responses are not realistic. Burnt-out practitioners are anxious, defensive, and not creative. ‘Good’ services that seek to protect practitioner wellbeing in the context of the current targets will encourage single-strand working—at the loss of creativity, adaptability, scope to implement problem-solving in a course of treatment to overcome barriers to helpful change. To cope with unrealistic access targets, low-intensity practitioners do more but offer less, and this is due to the detriment of patient care.

Differences between high-intensity CBT and low-intensity interventions It is very common for low-intensity psychological interventions to be confused with cognitive behaviorual therapy (CBT). This confusion arises from the fact that we do teach trainee practitioners ‘low-intensity CBT’ (LICBT) on the core training programme which draws on the theory and evidence base that underpins CBT. A grounding in LICBT is a grounding in pragmatic ‘here and now’ work, and in the values and principles of collaborative patient care and the core treatment strategies that form the foundation of the approach. This table is intended to highlight key differences between CBT and LICBT. The most useful reference for some further reading on this topic is the outstanding discussion paper The concept and definition of low intensity cognitive behaviour therapy by Roz Shafran and colleagues that was published in Behaviour Research and Therapy in 2021 (Table 3.1).

TABLE 3.1  Definition of LICBT. Element of the assessment process

‘High-intensity’ or traditional CBT assessment

Problem identification

CBT psychotherapists are trained to recognise and assess a range of mental health difficulties including common mental health problems and more severe and enduring conditions

Low-intensity assessment is designed to be an introduction to psychological treatment for common mental health problems Practitioners are trained to recognise but not diagnose common mental health problems as well as being able to identify (but not treat) more severe, complex, and enduring problems accurately

Formulation

Is idiosyncratic and longitudinal. That is, it describes a unique picture of the problem and takes developmental events into account

Uses a simple recognised model, typically this is an Autonomic, Behavioural, Cognitive ABC model, or Padesky’s five areas model to produce a descriptive case of conceptualisation (Padesky, 2020). Formulation gives the description of how the symptoms or elements of the problem interact to maintain the problem

Duration

Assessment might be completed over multiple 50-min long appointments depending on the complexity of the problem

Can be completed in one 45-min long appointment. Some services accept shorter triage assessments as sufficient to start treatment

Use of outcome measures

In the IAPT context, the IAPT minimum data set is completed at every appointment and the use of anxiety disorder-specific measures is common Outside of an IAPT/stepped care system, practitioners follow service protocol or their own preference if in private practice

In an IAPT or other stepped care context, the IAPT minimum data set is completed at every appointment. Anxiety disorder specific measures can be used to identify and assess the severity of specific anxiety disorders and might inform a decision to refer a patient to CBT or another more intensive talking therapy

Primary approach

Will often have a ‘big C, little B’ emphasis—the cognitive intervention has primacy over the behavioural

Is a problem-solving goal-focused behaviour-change approach, using behaviour-change theory to support selection of whichever intervention or strategy that will reduce barriers to behaviour changes that are intended to break the maintenance cycle identified in the formulation, and progress the patient towards their treatment goal

Low-intensity assessment in IAPT

Adapted from Shafran, R., Myles-Hooton, P., Bennett, S., Öst, L.-G., 2021. The concept and definition of low intensity cognitive behaviour therapy. Behav. Res. Ther. 138, 103803, ISSN:0005-7967. https://doi.org/10.1016/j.brat.2021.103803.

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What is our model and method? We talk about ‘low-intensity interventions’ but it’s worth pointing out that the interventions or behaviour-change strategies that we deliver are not what defines the low-intensity psychological interventions approach. On a graduate and postgraduate certificate programme, we are given 45 teaching days, students have contact with the teaching team on up to 30 of those days, and only 6 of those days are dedicated to teaching the theory and stages of behaviour-change strategies or ‘interventions’. The rest of the time is spent on teaching students the context of their role, the common factor skills, and the structure that allows us to make safe and efficient use of limited contact time with patients. We also dedicate a third of the programme to understanding and celebrating diversity, focusing on different experiences and identities and how to adapt our structures to those characteristics and identities. What defines this approach is not what we deliver but the structures that guide how we collaborate with a patient to define a problem, identify a goal, and navigate past any barriers to the changes that will take the patient from the problem, towards their goal.

Competition After the first couple of years of the IAPT programme, implementation vacancies for trainee Psychological Wellbeing Practitioner (TPWP) posts became highly competitive. A trainee PWP would be employed in an IAPT team for a year and receive Health Education England-funded training that provided a qualification that enabled you to work anywhere in the country. Being paid to train is a strong incentive in any field of work. In psychology, in the gap between completing a bachelor’s degree and beginning training on a doctoral level programme, it was almost unheard of. In the year that I applied I was blissfully ignorant of the wider world of psychology. I was in the same happy position as many people who wouldn’t stand a chance at a low-intensity training place in 2022. I wanted to do a job that would let me help people, and my personal qualities and life and work experience up to that time had equipped me with a good foundation for low-intensity psychological practice. Even in 2010, I nearly didn’t get a training place. I found out later that in the third year of IAPT implementation, the funding that had been earmarked to train the necessary

workforce to deliver IAPT as intended was not provided; the new Conservative-Liberal Democrat coalition government had different budgeting priorities than their labour predecessors. My IAPT team had negotiated funding for eight trainees and was working with local commissioners to find more. Lucky for me the local Primary Care and Mental Health Trusts found the spare change for two more PWP training places under the settee cushions and I was offered a place. Lucky for the Trusts too; I was one of only two of the trainee cohort of 10 who stayed in low-intensity practice. By 2019, my IAPT team would get more than 400 applicants within a couple of days of a trainee PWP job advert being released. The majority of those applicants were recent psychology graduates with a couple of years of paid or voluntary work experience in a mental health setting. The requirement of relevant prior work experience has to be nonnegotiable. We can’t get our trainees through everything that they have to learn and practice in the training year and initiate them into the unique world of mental healthcare service provision at the same time.

Training a profession A year-long training programme can function in two ways. It can be a starting point for professional life, a gateway to the responsibilities and work experience that will equip you with the values, attitudes and knowledge that characterise someone with a core profession. Or, the training might enhance preexisting knowledge and skills that were accumulated in another field of work. We have always attracted a number of applicants who have got preexisting professional qualifications and experience—usually in occupational therapy, education, or social work—there is a good case to be made (and I will try to do so in Chapter 11 of this book) that low-intensity psychological training is an exciting enhancement to the skill set of people with core physical health qualifications such as physiotherapist, nurse, and occupational therapist. The majority of the people who come into low-intensity psychological practice tend not to have worked in a professional role before they start their training, the majority of our trainees are younger than 30 and have often got just a year or two of work experience in a related area before they are released into the wild as trainee low-intensity psychological practitioners. There are always exceptions to this type of broad generalisation; I have taught people in their 50s with medical degrees as well as people in their early 20s with no degree-level qualification. They all make equally good low-intensity practitioners, if you get the training right. There are arguments made by some of the academics who are interested in low-intensity work that the low-intensity role should not be considered a profession. I won’t repeat those arguments here; they are already in the literature. I would say that the responsibilities carried by low-intensity psychological practitioners, the unique combination of skills and attributes that they are required to offer in their roles, and the pivotal part that they play in making the IAPT programme a success—a



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part that cannot be replicated by the other professions within the programme—all argue for the recognition that is provided by professional status. How training fits into our developing identity as a profession is explored more in Chapter 11.

Can training help with burnout? Accredited low-intensity training courses last 1 year and include a maximum of 30 days of direct teaching (clinical practice with supervision, self-directed learning and self-practice, self-reflection make up the rest of the programme), according to the curriculum in 2021. There’s a lot of material to fit into those days. Some courses are creative with the time that they provide; they squeeze in extra sessions and tailor the content to prepare practitioners for the realities of clinical practice in IAPT. None that I know of, teach specifically about vicarious trauma, compassion fatigue, and burnout. Most courses now (a revolutionary innovation that has become more common over the last half dozen years) hold sessions on practitioner resilience and self-care. On top of this, self-practice of the low-intensity techniques, with reflection, is mandated in lieu of the requirement to access personal therapy that is a condition of training in other modalities. Basically, we require students to practice what they preach, in the firm and genuine belief that the low-intensity CBT-based techniques are a distillation of excellent self-care advice. Of course, an emphasis on personal practice and resilience over an acknowledgement of the potential cost of caring in high volume reinforces the predominant narrative in the IAPT programme that if you struggle because of the work that you do, then that is a personal failing and nothing to do with the system. Throughout my years in practice within IAPT, I was haunted by the echoes of the message that this system was ‘evidence-based’, that it had been designed with care and forethought and was informed by data, so the system could not be wrong, the problem must be me and the other staff who either quietly left, or who shared their suffering over hurried cups of tea in the staff kitchen.

Some solutions are worse than the cure I have heard this message repeated more explicitly in the last year when at least one IAPT service hired a private consultant to teach staff that the problem of burnout within IAPT—and it really is a problem as multiple staff surveys have shown—is caused by bad hiring practices. According to this new school of thought, IAPT services should screen out applicants with a history of depression or anxiety to ensure that they hire people with the necessary toughness to go the distance in IAPT. I’ll be honest; my language wasn’t fit for polite company when I learned that public money had been spent on training that promoted this idea. Implementing these principles in hiring might reduce burnout in the workforce but I suspect that we would very quickly end up with services that provide a type of treatment but no care. The implication of this short-sighted idea is that IAPT would function better if the practitioners who work in the programme were less experienced in the types of suffering that they are hired to relieve. It also implies that an experience of depression or anxiety leaves the person with that experience lastingly vulnerable. Relapse does happen, but I don’t like the implication that long-term and effective management of these conditions isn’t possible, if that’s true then we need to go back to the drawing board for the treatment of common mental health conditions, quickly.

Don’t be common Another proposed solution to the problem of practitioner burnout came across my inbox recently. Some trainee low-­ intensity practitioners had been advised not to ‘paraphrase’ when they were in conversation with their patients. The ‘common factor skills’ of empathy, paraphrasing, verbal summary, and offering reflections of the spoken and unspoken content that the patient communicates to you are core skills in all the psychological professions. These skills are foundational to the low-intensity clinical method. You must be good at these competencies to work well with people. The advice to low-intensity trainees not to paraphrase was explained this way: paraphrasing involves accurate reflection of what the patient has communicated to the practitioner; this accurate active listening might increase the risk that the patient would disclose more emotive or trauma-related content to the practitioner. Or, and bear with me here, that the patient might feel safe and trusting with the practitioner, which is kind of what you’d hope for if you are talking to a professional about your experience of a mental health condition? We know that contact with trauma experience in a helping environment does carry risks for the practitioner. I’m not sure that offering less effective care because you’re frightened of what your patient might say is the answer. It might be better to make sure that our patients understand the limitations of what we can offer and contract that some details won’t be shared. We could improve training and supervision so that low-intensity practitioners are supported to know how to skillfully manage the content of an appointment, get the information needed to make a good treatment recommendation, and not re-traumatise someone.

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Types of practitioner Once training is completed there are, broadly speaking, three ways that a low-intensity psychological practitioner can engage with their work, I am going to describe them here and think about the impact of these styles on patient engagement and outcomes as well as practitioner wellbeing.

The manualised practitioner The first is to follow generic manualised, sometimes scripted, assessment, and treatment protocols with little deviation. These scripts are sometimes taught during training or required by the team that employs the practitioner. Algorithms (that may or may not be explicitly written down) determine which protocol is followed in each case. Sometimes this is more specific and the content of each session—which stage of an intervention should be completed during an appointment—is predetermined. This style tends to bring out consciously incompetent, somewhat anxious practitioners who struggle to develop and trust their clinical judgement. They might be nervous about going ‘off script’ to respond to the ‘here and now’ content of an interaction with a patient. The patient experience of the practitioner who uses this style of work might be interpersonally cold—the practitioner might be unresponsive to the nonverbal content in their interactions or might fail to use the common factor skills of reflection, empathy, and summary to engage and work collaboratively with the patient. Still, there is a reasonable chance of clinical recovery if a good enough algorithm and script are being followed and if patients are carefully screened for mildto-moderate, simple presenting problems with no clinical risk. We’ll call this first style the manualised approach.

The free for all practitioner The second way that some low-intensity practitioners go about their work is to complete training in the low-intensity interventions but acquire only a very basic understanding of the theories and principles that are taught during training. Once qualified, they do not seek to deepen their understanding of the approach but rely on instinct and ‘felt sense’ to guide the work that they, the practitioner, offer to the patient on a session-by-session basis. They use the ‘common factor skills’ that are employed in the majority of talking therapies but draw on the competencies and skills that are specific to low-intensity work only when it arises organically within an unstructured conversation. These practitioners might be unconsciously competent in the low-intensity model and method, but there is a high risk of unconscious incompetence with this style. The patient experience of a practitioner who uses this style is likely to be warm, empathetic and sympathetic, but the odds of getting access to a psychological treatment that has been tested in research conditions are low. This type of practitioner is likely to try to work with everyone who they meet, no matter how complex the presenting problem is, with the risk of delaying access to the appropriate level of care for more severe or complex presenting problems. We’ll call this second style the free for all approach or, more formally, clinical drift.

The reflective practitioner The third way that some low-intensity practitioners develop is to complete the training and learn actively whilst formal teaching takes place. In addition to this, the practitioner learns to use the principles of reflective practice to evaluate, analyse, and learn from their own and other practitioners’ work both during and after training. They stay up to date with developments in the literature and evidence base and read critically. Their understanding of the theory that underpins the interventions deepens and they become craftsman-like in how they apply the clinical method. These practitioners are consciously competent—they know what they are doing and why. They acquire a deep understanding of the theories and models that underpin the approach that they are employed to deliver, and are adaptive enough to apply that understanding in a unique pattern that is specific to the individual who they are working with. The patient experience of these practitioners is often that they are interpersonally competent—good listeners, warm, and empathetic—but they use these common factor skills to facilitate a focus on the model and techniques that are specific to this approach. Their priority is to educate and support the patient to make changes that will reduce the severity and impact of the presenting problem and equip the patient to achieve their goals. We’ll call this third style the reflective approach.

Research to practice The manualised approach fits most comfortably with the idea of ‘evidence-based practice’ that gets tossed around so carelessly in this field of work. Evidence-based practice would mean that practitioners offer information and forms of words



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that adhere closely to those manuals used in controlled and peer-reviewed published research trials. In concept, this way of working would mean that every patient would receive exactly the same treatment from any practitioner who they engage with, with equal chances of a good outcome from treatment. The implementation of ideal ‘evidence-based practice’ would mean that every patient receives a treatment that has been tested in stringent laboratory conditions (or the closest social sciences equivalent to laboratory conditions).

Exclusion One could (and is!) argue that whilst a manualised intervention might be the most ‘correct’, that is, the most in line with the way low-intensity psychological work was designed to be delivered by academic theorists, it comes with a higher risk of excluding patients who have identities and life circumstances that were not represented in the patient groups in the research trials that form the ‘evidence base’. Excluded groups are likely to include people who live in chronic adverse circumstances like occupational disadvantage, financial worry, and housing insecurity. It might include people with various intersections of minoritised identities and experience, who are often not well represented in psychology research trials (Roberts et al., 2020). Working with patients who have experienced a range of life experiences places a requirement on the practitioner to work in a person-centred way; engaging with the patient with curiosity and exercising judgement to make adaptations to the material that is offered, how it is explained and delivered. The practitioner also has to be able to take account of additional factors like how experiences of systematic disadvantage and discrimination might affect the way that the patient engages with healthcare services and interprets the concepts that are communicated during treatment. James Spires writes more about this in Chapter 4. These systematically excluded people might not see themselves represented in the material that this style of delivery relies on heavily. Manualised interventions often quite literally require the practitioner and patient to progress through an approved written self-help resource—or manual—together; lack of representation in case studies and vignettes that illustrate the principles and techniques in action means that patients with minoritised identities and experience have to work harder to engage with it. If the manualised interventions are also delivered in a uniform style, the interpersonal dynamics might exclude patients who have different learning styles or who need to spend more time problem solving before they put the new learning into practice. The requirement to deliver manualised and uniform interventions will often be accompanied by ‘pro formas’—prewritten templates that the practitioner is expected to use to record the content and outcome of an appointment with a patient. These pro formas are often so detailed that they essentialy prepopulate the time that the patient and practitioner spend in conversation which inhibits genuine interpersonal connection and responsiveness, which puts collaboration and rappor— and therefore outcomes from treatment—at risk. This style of practice carries the risk that the practitioner will become bored with the repetitive nature of the work. It leaves little scope for flexibility, creativity, and genuiness. There is a risk that the interpersonal dynamics in this style of work might feel unrewarding which can have consequences for practitioner burnout and retention.

Manualisation as the first step towards integration In the years prior to the publication of this book, an exciting development has taken place with the development of a lowintensity treatment protocol based on Cognitive Analytic Therapy (CAT), as opposed to the Cognitive Behavioural Therapy (CBT) that has been the underpinning approach for the majority of low-intensity psychological work. Cognitive analyticguided self-help for the treatment of anxiety in IAPT services (Meadows and Kellett, 2017) was developed with the intention to give patients more choice in the treatment approaches that are available for mild-moderate anxiety in IAPT services, and has shown promising outcomes. A manualised CAT-guided self-help protocol was written by clinician researchers at the University of Sheffield which specifies tasks and content for six to eight treatment sessions. The low-intensity practitioners in the early modelling trials were rated using an established low-intensity competency measure (Kellett et al., 2020) which recognises that the skills required to deliver CAT-based interventions are almost identical to those needed to deliver CBT-based interventions. Some experienced low-intensity practitioners and educators were invited to test the interrater reliability of the CATGSH practitioner competency measure. On reading the manual and listening to a treatment session tape, one of them exclaimed with awe and delight ‘You’ve developed a good low-intensity treatment for social anxiety disorder!’ (low-intensity CBT for social anxiety disorder is problematic at best and dangerous at worst). The lead researcher simply nodded as if that was too obvious to comment on.

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Thoroughly researched and properly developed CAT-based interventions are a good sign of things to come. To work adequately and within the time constraints of low-intensity psychological interventions, it seems likely that this approach will increasingly become recognised as an integrative approach. Integrative work doesn’t mean that practitioners ‘have a go’ at implementing any strategies or interventions that they find interesting; true integrative work means that you undertake substantial training to properly understand the model and approach that you will implement and you apply that model and those techniques with careful, conscious decision-making with accountability to a supervisor who is at least equally qualified in the approaches that you use. We will always need to have core training in Cognitive Behavioural Therapy-based interventions; this approach holds the evidence base not just for the therapeutic interventions but also for the principles of collaboration, patient empowerment, and self-efficacy and between session work that characterise low-intensity work. There has long been a feeling that CBT-based interventions are not sufficient to enable low-intensity practitioners to function to the full potential of the role in primary care. As low-intensity psychological interventions expand into secondary care mental health settings with the emergence of children and young people’s wellbeing practitioners and mental health wellbeing practitioners, we will need the flexibility to adopt theory and principles from approaches like Dialectical Behaviour Therapy and IPT and whole systems approaches to offer an effective responses to a range of different presenting problems. Low-intensity person-centred counselling has been proposed—and there are thousands of qualified counsellors who could readily provide that service without any need to re-train low-intensity practitioners—as has Low-Intensity Acceptance and Commitment Therapy and Low-Intensity Compassion-based interventions. As each different theoretical approach is adapted for the constraints of low-intensity work, we will have to start with a manual. This will be required for the research trials that will have to be conducted to validate the adaptation of the new low-intensity interventions and strategies. Practitioners who implement clinical interventions based on an unfamiliar therapeutic model will need the boundaries of a manualised intervention to ensure safe and ethical practice and prevent therapeutic drift into the ‘free for all’ style. Once their understanding of the model deepens and supervisors become experienced enough to provide expert and safe guidance on the model then practitioners will progress to the reflective practitioner style and the reliance on a written manual will reduce.

Problems with ‘free-for-all’ practice The free for all style is possibly most appealing to those people who trained in a different therapeutic approach or core profession before they came into low-intensity psychological work. They have a nonspecific desire to ‘help people’ and a pragmatic desire to have paid employment. We see this style emerge sometimes when a low-intensity practitioner has qualified as a person-centred counsellor but can’t afford to work the hundreds of unpaid hours that are needed to reach the standard for accreditation. Sometimes ‘free-for-all’ practitioners worked as support workers in mental health settings where their employer sent them on lots of short courses that covered a variety of approaches and techniques in a superficial way and they are reluctant to discard ideas and techniques that were helpful in that setting. Low-intensity practitioners who are not just willing but eager to try to work with every patient who self-refers to IAPT go some way towards plastering over the demand for practitioners who can work with the volume of severe, complex, and long-standing difficulty that we see in primary care psychology services. What they deliver can feel ‘nice’ for the patient. I have heard examples of appointments where the patient and practitioner had a very comfortable and friendly chat about how the patient was feeling. The practitioner might offer some words of sympathy or an analysis of why they think the patient is experiencing their difficulty—an analysis that is not based on any model taught on an accredited low-intensity course—and some words of wisdom about what the patient ought to do next to fix the problem. Sometimes that advice pays lip service to one of the interventions that we teach on the accredited training programmes but more often it is wholly opinion based, or based on a therapeutic model that is not adapted for low-intensity interventions yet. Practitioners and some patients might find the interpersonal dynamic rewarding and refreshing, but the patient is not reliably offered a tested psychological intervention. A scripted, overly manualised treatment style might be off-putting and leave the patient feel that they are on a conveyor belt of treatment; the free-for-all style can leave a patient feeling stuck, with little sense of their ability to independently make changes that will affect how they feel. Of course, this can only happen when the clinical supervision that the practitioner receives fails to detect weaknesses in practice and when low-intensity practitioners are not encouraged or supported to reflect on their work in light of the theoretical model and research evidence base.

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Getting through the door We are writing this book based on observed practices within the IAPT programme where low-intensity practitioners work with adult patients (sometimes this is expanded to include the 16–18 age group depending on local commissioning arrangements). Teams organise the process of assessment differently and as low-intensity interventions expand into educational settings and secondary mental health services for adults and children and young people the variety of systems and processes will expand. In some organisations, there can be a very brief screening call with an administrator who can follow an algorithm to determine if further assessment is warranted within the team, or if the patient should be directed to another service for more appropriate care. This screening might be followed with a ‘triage’ assessment of 20–30 min in which a practitioner collects more information about the presenting problem and the patient’s goals for treatment. At this stage, the patient might be

offered a choice of ‘first line’ interventions which are usually group-based psychoeducation courses or computerised CBT; these interventions are often quick to access and reduce the direct contact time between a patient and a practitioner. Some services make use of a first line intervention a requirement—no other treatment options can be accessed in the service until one of these are completed and shown to be ineffective for the patient. This is certainly one way to interpret the principles of a stepped care system, although the problematic nature of reducing treatment choices to low-intensity options alone, regardless of the presenting problem, doesn’t need to be spelled out. The purpose of the assessment process is to identify the ‘presenting problem’, that is to identify which common mental health problem the patient is seeking treatment for and to work with the patient to understand what is keeping that problem going, and evaluate if treatment can be safely offered within the limitations of the service that the practitioner works for.

Assessment It is not the purpose of this book to go into the detail and the ‘what’ of the low-intensity treatment interventions and strategies. What I have tried to do in this chapter is to emphasise the paramount importance of the low-intensity assessment, and I am going to make that more specific now. Within a few months of starting low-intensity clinical practice, accurate assessment and problem identification often become the low-intensity practitioner’s strongest skill. This is our forte, when we are given the time and appropriate support to do it well. Pamela Myles-Hooton’s excellent chapter on low-intensity assessment in the 2020 Low-intensity CBT Skills and Interventions: a practitioner’s manual (Farrand, 2020) provides more information and consideration than the scope of this chapter. In brief, a low-intensity problem-focused assessment can be completed in 45 min when the presenting problem is a simple episode of depression or a common anxiety disorder and there are not substantial complications like significant clinical risk or complex situational factors. The assessment structure efficiently condenses a process that involves several stages and the use of a complex set of skills. Although this process can be completed in one appointment, elements of the assessment process might be completed before a patient speaks to a practitioner (for example, collection of the minimum data set questionnaires and demographic details might occur before an initial appointment), or in subsequent sessions where the assessment process overlaps with the start of treatment. For example, it is rare to be able to collaboratively complete a formulation and explain it properly to the patient in the same appointment as the initial information gathering, risk assessment, introduction to the service and the minimum data set, and a discussion of treatment options takes place. This can lead to the formulation being skipped and practitioners implementing a treatment intervention based on a conversation along, without sharing the organising model with the patient. Whether the stages of a complete assessment are ‘done’ in one appointment or more, it is important that they are all done, or there is a risk that the patient will not be equipped with a good enough understanding of the process of change to become their own therapist when treatment ends.

The reflective practitioner in action We’ve looked at the personal styles that can be used to deliver low-intensity interventions. These have been described almost as caricatures to emphasise the priorities that can influence delivery of the approach. On the one hand, a fanatical adherence to the stringent form of ideas and protocols that meet the standard for use in research; on the other hand, a disregard of tested methodology in favour of an emphasis on gut instinct and interpersonal connection. The next pages will examine the third proposed option; a practitioner who understands the theory behind what the protocols describe who can use their interpersonal and communication skills to provide a useful amount of theoretical information and bring out the patient’s own strengths to use that information to address the problem that is preventing them from achieving their goal. To develop expert craftsmanship in this approach, the practitioner has to use reflection not to replace learning from research with learning entirely from practice, but to ensure that their practice stays consistent with the true principles of the theoretical model. In this way, decision-making is informed by the research evidence but the practitioner retains the flexibility to respond to the individual who they are working with, fitting the work to the patient, not expecting the patient to fit into the work.

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Diagnostic labels Low-intensity psychological interventions have got a slightly complicated relationship with the idea of diagnostic labels. We are taught to be familiar with the ICD and DSM (in various editions and revisions over the years) diagnostic manuals. IAPT reports its outcomes using codes for common mental health problems from the ICD manual, so practitioners are expected to indicate what diagnostic label they are providing treatment for on their record keeping system, the system links this to the outcome measures that are collected session by session, and this information is stripped of any patient identifying information and reported back to the central IAPT database every month. This is where IAPT’s ‘recovery’ numbers come from. However, we stress to low-intensity practitioners that they are not qualified to provide a diagnosis of a medical condition. Indeed, we absolutely are not. So, what does that ‘problem descriptor’ code really mean? It means that out of all of the

information gathered throughout the assessment process, the indicated problem descriptor best-fits the pattern of symptoms that the practitioner is trying to help the patient to manage. The names of the common mental health problems ‘depression’, ‘generalised anxiety’ (more familiarly known as GAD), ‘panic’, and so on all give the practitioners in the team a shorthand that is both time-saving and helpful when it comes to communicating with our medical colleagues. It is so much easier to say ‘I’m supporting this person to manage symptoms of depression’ than ‘I’m working with someone to break an unhelpful pattern of avoidant behaviours that is maintaining low mood and the occurrence of frequent negative automatic thoughts that also serve to maintain the low mood state’. ‘I’m having a GADdy moment’ is also useful office shorthand for ‘my head’s spinning with everything that I’m trying to manage and I can’t think straight, bear with me!’

An effective course of low-intensity treatment Start with an assessment of the presenting problem This assessment process might not be fully completed in one appointment but it will involve the practitioner and patient reaching a shared definition of the problem that the patient wants to resolve; this includes an acknowledgement of the symptoms that the patient is experiencing, triggers and onset of the problem, and a review of the impact that the problem is having on valued activity (essentially, how difficult is it to do usual activities because of the symptoms). A shared understanding of what is maintaining the problem is formulated using a simple model to illustrate how small changes can trigger, maintain, and, hopefully, resolve the problem. A behavioural goal for treatment is elicited; this is a statement of what the practitioner and patient will work together to achieve through the practice of a low-intensity intervention. Standardised outcome measures contribute to this programme and a risk assessment or review is completed at every patient contact. All of this is facilitated in a collaborative manner, the practitioner engages with the patient with warmth, a nonjudgemental attitude, and offers empathy.

Use supervision The high volume caseloads that low-intensity practitioners hold can’t be cared for safely without adequate supervision. At a minimum, a practitioner should have 1 h every week to review their caseload with a supervisor. In this forum, every assessment is reviewed and the outcome of the assessment is either agreed or revised. Every patient on the practitioner’s caseload is reviewed every 4 weeks, or more often, if there are concerns about risk and safety or if the practitioner has questions for their supervisor about a piece of work. Chapter 8 of this book provides more detail about supervision for low-intensity practice.

Choose an intervention Once the presenting problem is defined and the cycle of thoughts, physical changes and behaviour that maintain it has been identified, the practitioner offers the intervention best-suited to move the patient away from that problem, break that maintenance cycle, and support movement towards their goal.

Keep track of progress Session-by-session reviews of standard outcome measures are used to keep track of change ‘live’ so that if the intervention does not bring about change, barriers and difficulties can be explored and problem-solved quickly. This is where things can get a bit messy because a lot of things can get in the way of the smooth progress of an intervention and the practitioner has to make ongoing judgements.



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Are they providing the right level and type of care? If so, are they providing the most helpful or appropriate low-­ intensity intervention? If you have started an intervention and there has been no change between sessions, do you introduce a different strategy or try to problem-solve what wasn’t working about the original choice? The importance of an accurate assessment really makes itself felt here, if you skipped over the formulation and didn’t reach a succinct and shared understanding of what the patient wanted to change and what they want to move towards, you’ll often find yourself flapping in the breeze once treatment starts.

Incorporate relapse prevention A rather devastating paper by Shehzad Ali and colleagues was published in 2017 that lit a fire under many IAPT services. The paper, titled ‘How durable is the effect of low intensity CBT for depression and anxiety? Remission and relapse in a longitudinal cohort study’ and published in the journal of Behaviour Research and Therapy, described a study that continued to monitor patient symptoms of depression and anxiety for a year after a course of low-intensity CBT was completed in IAPT. 53% of the patient respondents relapsed within a year. IAPT has always bragged about its recovery rates, and it is rare for a service to report less than 50% recovery by the end of treatment, but this data about relapse cast doubt on the value of those outcomes. What good was recovery if it wasn’t going to last? The idea of relapse prevention in low-intensity practice is a bit of a misnomer. We work with people (or we should be working with people) who need support to self-manage difficulties that often arise naturally and predictably from demanding life circumstances. Most of us will not be happy, stress-free, and have no worries for the rest of our lives; the aim of a low-intensity intervention is to support people to learn how to self-manage sometimes overwhelming fluctuations in their experience, not to cure a disease. So, we end treatment with people not in the expectation that they will never be sad or scared again, but with the hope that they are better equipped to understand and respond in helpful ways when those difficult experiences arise. Above all, we hope that we have built up a sense in the person that they can do something that will affect their experience, and supported them to be problem-solvers. There is an important step before contact with a practitioner ends where we should consolidate with the person what they have learned over the course of their time with us. This is, effectively, checking in and reinforcing the patient’s ‘conscious competence’ in understanding and responding to their difficult experiences. A good relapse prevention plan will identify protective daily, weekly, and monthly routines that the patient can establish, identify early warning signs that the patient can notice—indicators that an unhelpful cycle is developing and a plan for how to respond to halt an emerging problem before it takes over. It will identify the patient’s strengths and resources and pull all of the threads of the low-intensity treatment together for future use.

Facilitated by the common factor skills Kuroda et al. (2021) identified ‘human support’ as significantly associated with successful interventions in a systematic review of randomised controlled trials of CBT-based self-help in primary care. The processes of assessment and treatment should all be facilitated by competent use of the common factor skills. The use of these skills ensures that the patient feels heard and validated. Difficulties are normalised without being minimised, by a practitioner who communicates warm and empathetic interest, without being sentimental and without pity. Effective use of reflection and summary ensures that the patient and practitioner have a shared understanding of what is happening, which fosters an equal power balance and collaborative work.

Reflective space In this chapter, I have attempted to outline one way that low-intensity psychological interventions can be understood as a distinct therapeutic approach. I have described some of the considerations around training practitioners that might affect the type of clinical work that is provided by practitioners both during and after initial training, and have emphasised the importance of the assessment process in making low-intensity interventions safe and useful for the patient. 1. This chapter starts with an anonymous quote from a person who holds a small view of the nature and scope of the lowintensity theoretical model and clinical method, and the competencies of our practitioners. How did that quote feel when you first saw it? And how does it feel now? 2. What were your thoughts as you read this chapter? Did you relate any content to your own experience? What did you agree with? What would you say differently? 3. How will you share your ideas and experience of this approach with other people? 4. Can you think of any ways to connect with other people who are interested in this approach, so that you can get a broader view on the world of low-intensity interventions and practice?

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Farrand, P., Dawes, A., Doughty, M., Phull, S., Saines, S., Winter, S., Roth, A., 2022. Development and application of criteria to evaluate written CBT self-help interventions adopted by Improving Access to Psychological Therapies services. Cogn. Behav. Ther. 15, E28. https://doi.org/10.1017/ S1754470X22000241. Haarhoff, B., Thwaites, R., 2016. Reflection in CBT. Sage. Hakim, N., Thompson, A., Coleman-Oluwabusola, G., 2019. An evaluation of the transition from BAME community mental health worker to IAPT low intensity psychological wellbeing practitioner. Cogn. Behav. Ther. 12, E15. https://doi.org/10.1017/S1754470X18000296. Hughes, C., Herron, S., Younge, J., 2014. CBT for Mild to Moderate Depression and Anxiety. Open University Press, England. Hutten, R. (2018). The making of psychological therapists: towards a psychosocial understanding of IAPT training, culture and practices. PhD thesis, University of Sheffield. Kellett, S., Simmonds-Buckley, M., Limon, E., Stride, C., Hughes, L., Hague, J., Millings, A., 2020. Defining the assessment and treatment competencies to deliver low intensity cognitive behavioural therapy: a multi-centre validation study. Behav. Ther. https://doi.org/10.1016/j.beth.2020.01.006. Advance online publication. Kell, L., Laville, A., 2021. Diversity and Inclusion Vignettes: For Psychological Wellbeing Practitioner Training Programmes. British Psychological Society. Available at: PWP Diversity and Inclusion Vignettes.pdf (bps.org.uk). Kuroda, N., Burkey, M.D., Wissow, L.S., 2021. Discovering common elements of empirically supported self-help interventions for depression in primary care: a systematic review. J. Gen. Intern. Med. 36 (4), 869–880. https://doi.org/10.1007/s11606-020-06449-y. Meadows, J., Kellett, S., 2017. Development and evaluation of cognitive analytic guided self-help (CAT-SH) for use in IAPT services. Behav. Cogn. Psychother. 45 (3), 266–284. https://doi.org/10.1017/S1352465816000485. Michie, S., van Stralen, M.M., West, R., 2011. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement. Sci. 6, 42. https://doi.org/10.1186/1748-5908-6-42. Moncrieff, J., Cooper, R.E., Stockmann, T., et al., 2022. The serotonin theory of depression: a systematic umbrella review of the evidence. Mol. Psychiatry. https://doi.org/10.1038/s41380-022-01661-0. Owen, J., 2020. The use of practice-based learning days on psychological wellbeing practitioner training programmes: a self-determination theory perspective. Psychol. Teach. Rev. 0965-948X. 26 (2), 19–25. Owen, J., Cross, S., Mergia, V., Fisher, P., 2022. Stress, resilience and coping in psychological wellbeing practitioner trainees: a mixed-methods study. Cogn. Behav. Ther. 15, E38. https://doi.org/10.1017/S1754470X22000356. Padesky, C.A., 2020. Collaborative case conceptualization: client knows best. Cogn. Behav. Pract. https://doi.org/10.1016/j.cbpra.2020.06.003. Available online 23 July 2020. Richards, D., Whyte, M., 2008/2011. Reach Out: National Programme Student Materials to Support the Delivery of Training for Psychological Wellbeing Practitioners Delivering Low Intensity Interventions. Roberts, S.O., Bareket-Shavit, C., Dollins, F.A., Goldie, P.D., Mortenson, E., 2020. Racial inequality in psychological research: trends of the past and recommendations for the future. Perspect. Psychol. Sci. 15 (6), 1295–1309. https://doi.org/10.1177/1745691620927709. Epub 2020 Jun 24. PMID: 32578504. Rolfe, G., 2002. Reflective practice: where now? Nurse Educ. Pract. 2 (1), 21–29. https://doi.org/10.1054/nepr.2002.0047. Schon, D.A., 1983. The Reflective Practitioner. Basic Books, USA. Tallon, D., McClay, C.-A., Kessler, D., Lewis, G., Peters, T., Shafran, R., Williams, C., Wiles, N., 2019. Materials used to support cognitive behavioural therapy for depression: a survey of therapists’ clinical practice and views. Cogn. Behav. Ther. 48 (6), 463–481. https://doi.org/10.1080/16506073.2 018.1541927. Thwaites, R., Cairns, L., Bennett-Levy, J., Johnston, L., Lowrie, R., Robinson, A., Turner, M., Haarhoff, B., Perry, H., 2015. Developing metacompetence in low intensity cognitive-behavioural therapy (CBT) interventions: evaluating a self-practice/self-reflection programme for experiences low intensity CBT practitioners. Aust. Psychol. 50, 311–321. Williams, C., 2001. Overcoming Depression: A Five Areas Approach. CRC Press. Williams, C., 2003. Overcoming Anxiety: A Five Areas Approach. CRC Press.

Further reading Shafran, R., Myles-Hooton, P., Bennett, S., Öst, L.-G., 2021. The concept and definition of low intensity cognitive behaviour therapy. Behav. Res. Ther. 0005-7967. 138, 103803. https://doi.org/10.1016/j.brat.2021.103803.

Chapter 4

Working with challenging social contexts James Spiers

Key aims of this chapter ● ● ●

● ●

Relaying the impact of socio-economic context on physical and mental health outcomes. Describing common concerns experienced by people in low-income demographics. To stress the requirement for a thorough assessment of need, clinical adaptation, and flexibility when working with social differences. Highlighting the importance of adequate resources and funding for health and social care services. Considering the potential benefits and limitations of low-intensity psychological therapy when working with complex social contexts.

Between a clinical rock and a socially hard place Low-intensity psychological practitioners will often encounter patients in IAPT services who present with a combination of mental health, physical health, and social difficulties, creating additional challenges for service suitability assessments. This can be particularly challenging when trying to determine whether a mental health problem is being maintained by social factors, e.g. poverty leading to depression and self-neglect, or whether social difficulties are being maintained by a mental health problem, e.g. avoidance of social engagement and employment due to anxiety or low esteem. Unless there is a good chance that the person’s mental health difficulties are being maintained primarily by maladaptive thoughts and actions, as opposed to fixed socio-economic factors, both the patient and their practitioner can struggle to gain a tangible foothold on achievable aims and a focus on which to commence low-intensity intervention. People who experience income inequality may also be more likely to encounter engagement barriers in the initial stages of therapy, and whilst they are no less likely to drop out of treatment than those from middle-income households once established in therapy (Self et al., 2005), there is also a higher likelihood of requiring longer treatment periods to achieve equitable outcomes, even when controlling for employment status (Finegan et al., 2020). This is particularly important given the increased risk of suicide when people experience socioeconomic disadvantage and pressured finances, including those who are at risk of losing employment stemming from downturns in the economy (Appleby et al., 2017). Therefore, adequately funded services proportionate to the needs of the local population are essential to ensuring equitable outcomes based on income demographics, see Clark et al. (2018).

Assessment challenges in low-income areas A good low-intensity psychological assessment combines the subjectively reported narrative of patient distress alongside a brief self-report psychometric measurement of symptom severity for the common features of anxiety and depression using the PHQ-9 (Kroenke et al., 2001) and GAD-7 (Spitzer et al., 2006), including a brief rating of social impact as part of a minimum data set (MDS). However, symptom severity can be temporarily exacerbated and fluctuate as a result of external social factors leading to severe acute episodes of distress at the start and also during therapy. It then comes as no surprise that high numbers of referrals to the IAPT programme from people living in areas of high social deprivation contain large patient groups who fall short of the mild-moderate anxiety and depression threshold of an IAPT service. In the absence of immediate risk or severe and enduring mental health diagnoses, people referred to an IAPT service are therefore deemed to fall under the umbrella of ‘common mental health disorder’. Sadly, both the patient and their GP can hit roadblocks in terms of IAPT service suitability if the patient’s history includes either fixed situational problems, homelessness, chronic childhood trauma, alcohol dependency, illicit substance use, or problems controlling anger.

Care in High Volume. https://doi.org/10.1016/B978-0-323-88492-1.00004-X Copyright © 2023 Elsevier Inc. All rights reserved.

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Social neglect A key risk factor that often gains less attention or probing in low-intensity assessment is what I would refer to as social neglect (a person being excluded from general society through a lack of social mobility as opposed to intentional self-withdrawal). Although it is common and in most cases routine to assess for self-neglect, and whilst there are natural limitations and boundaries in terms of our ability to physically assess a patient, shame can inhibit disclosure as to the depths of the problems that people may experience. For many of the patients I assessed, the signs and symptoms of self-neglect would often stem from being socially ostracised with insufficient money to eat, and heat their homes. I saw countless people in my low-intensity clinics who I would deem as experiencing social neglect, those who had struggled to ask for help and had such few social contacts that the extent of their difficulties had never previously fully come to light. Increasingly more common since the introduction of the long-term conditions arm of the IAPT programme were people who presented with comorbidity of psychological and physical health problems. Many struggled to maintain employment due to their physical health, losing the little contact they had with colleagues, and having attended a benefits agency assessment alone with no advocacy; they had struggled to articulate the depth of their difficulties and subsequently failed to be awarded financial support. Some people were later supported by local charity organisations to appeal the decision to decline their benefit claim, but this process was often very lengthy and without any guarantees. More recently, a significant amount of my time working as a trainee psychologist in NHS services was spent writing supporting letters for personal independence payment (PIP) appeals, albeit the person having to choose between eating and heating in the meantime. Not good conditions on which to begin intensive trauma-focused psychological therapy in a tier-four service, and not the most efficient use of NHS time, given that the NHS is funded to provide psychological and physical healthcare, yet often crucial to support the person with their basic needs. In several cases that I came across in secondary care services, it had taken the person over a year to appeal their benefits decision, supported by their appointed Community Psychiatric Nurse (CPN) after the depth of the person’s problems had only truly come to light once they were admitted to hospital following a near-fatal suicide attempt as a result of hopelessness about their situation. My general sense from practice is that psychology and psychological therapy can often be limited where people are experiencing problems with depression stemming from significant social neglect that is being maintained by external factors outside of the person’s control, as opposed to psychological problems lying within the person’s scope of what they are able to change. Arguably, psychology and psychotherapy need to be better integrated with their local community and social services, see Knifton and Inglis (2020), but there can also be a fine line here as to whether we are, at times, at risk of drifting beyond our scope of knowledge and training into social work. In England, social work is a regulated profession requiring registration with a professional body. It is also vital to recognise, given that the IAPT programme was set up based on the projected cost savings through countering unemployment and employment absence, that whilst psychological barriers may exist in terms of someone’s opportunity and their ability for employment, these are not always processes that can be easily resolved with short-term brief psychological intervention. Many of the people I have assessed would often arrive motivated by a need to ‘prove’ that they were taking measures to tackle their problem with depression in order to avoid further benefits penalty that would worsen their already impossible financial situation. One of the problems here is that removing someone’s income benefit or support on the basis of perceived physical ability for employment can then reduce their opportunity to fully benefit from psychological intervention and, in some cases, would require years of psychological work. So what does someone do if they have no income, can neither access suitable therapy nor feel able to enter the workforce? If the person’s process is to neglect and ignore their own needs, mapping onto their history of being neglected and ignored, they will often slip out of sight and deteriorate in silence. Equally, given the desperate situations that they can be faced with, some will spend the little money they have on alcohol and illicit substances to detach from the pain of their situation.

Social disorder The history and the social context surrounding someone’s problems with depression and anxiety can also dominate and blur the lens of the clinical focus. Common narratives within IAPT teams (who often do not have lived experience of complex social contexts themselves) can be that the patient’s immediate presenting problem is “situational” in nature (poverty, bad neighbours, housing), and therefore requires resolve or support prior to commencing psychological therapy (Box 4.1).

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Box 4.1 During my training year as a low-intensity practitioner, I worked in an area in the North of England where the economic demographic was very mixed. One of the GP surgeries that I was based in had a wealth of clinical experience and expertise; clinicians and administrators knew their patients well and were one of the few surgeries remaining that were mostly staffed with permanent rather than locum staff. As I was training with a third-sector service at the time, my electronic diary did not link up with the NHS booking system. I would be handed a sheet of paper each morning with a list of the patients that I would see. One particular GP used to occasionally write the letters S.L.S by the patient’s name. Having had no formal medical training, and numerous Google searches shedding no light as to what this meant, I scoured the DSM-5 (APA, 2013) and ICD-10 (WHO, 1992) and was pretty certain this did not relate to a recognised psychological problem. Was it a degenerative neurological disease? A medically unexplained symptoms (MUS) condition? Eventually, I plucked up the courage to ask the GP in question at a chance meeting in the staff room. JS: Hi, is it Dr. Smith? Dr. S: Yes, it is, you’re James the counsellor, right? JS: I’m a Psychological Wellbeing Practitioner with the IAPT service. Dr. S: I hope you are settling in.

JS: I’ve been meaning to ask, I keep noticing the term S.L.S written on the referrals, I can’t seem to work out what it stands for. Dr. S: S.L.S? You mean, Shit Life Syndrome? [laughs] Apologies, it’s something I got used to doing with the counsellor we had before, I thought it was a ‘counselling thing’? JS: [not sure how to respond] It’s not something I’ve come across before. Dr. S: Oh really? You will definitely see a lot of it working here. We spent the remainder of our lunch break talking about S.L.S. Dr. Smith had a specialised interest in mental health, but also (despite the dire acronym) recognised that people living in disadvantaged circumstances with little autonomy over changing their situation would likely experience a negative impact on their psychological wellbeing as a result. Dr. Smith had not used the term S.L.S as a pejorative term towards the patient but was trying to indicate to the IAPT practitioner in the surgery to be aware of overly pathologising the patient’s circumstance, the GP’s way of protesting the ICD-10 categories that were mandated to be assigned in order for the patient to gain access to the IAPT service. Essentially, S.L.S was a way of demonstrating that the person was more likely suffering from depression and anxiety as a symptom of problematic social and political systems.

Problems with suitability So where do patients go for help when they live in challenging social contexts and are experiencing psychological distress? If their symptoms can be loosely defined by DSM-5 or ICD-10 criteria, yet are deemed not suitable for secondary or specialist services, the GPs in England often have little choice but to refer the patient to their local IAPT service. Patients can then be met with further barriers stemming from suitability criteria that close a metaphorical door in their face. Assessing patient suitability where someone’s narrative is enveloped by additional complexity such as poverty, social challenges, and a higher likelihood of social disadvantage is often challenging where assessment is time pressured. Patients who present with issues around homelessness, anger, or problematic alcohol and substance use are commonly rejected at the assessment stage, often risking the cementing of previously held beliefs of being unworthy of the free [at the point of access] care available to middle England. One of the most common challenges I encountered were people who experienced both anxiety and depression but also described their primary problem as struggling to manage anger, with many people referred to primary care specifically for anger management. Whilst anger is a normal human emotion, it is less explicitly discussed in much of the low-intensity training or mainstream guided self-help (GSH) material. Yet, it is as commonly present in low-intensity intervention as any other therapeutic modality, just more recognisable as an IAPT-appropriate problem when it is turned towards the person themselves, e.g. self-critical thoughts and self-harm. Externalised presentations of anger are also commonly witnessed in low-intensity sessions. For people whose interpersonal process is passive-aggressive, we might see polite terms being used, such as “irritability” or “agitation.” For those expressing explicit rage, this could often get tangled up in assessing the person’s ability to suppress urges and impulses. Here, the suitability for an IAPT service becomes less clear, where people are acting on impulses, punching doors, walls, or other people.

Anger and low-intensity intervention My experience of working with anger and rage as emotional components of the persons’ ‘vicious cycle’ in a low-intensity formulation is that it is typically circumvented in low-intensity treatment. Explicit reference to anger, similar to that of shame and guilt, often creates conflict for the low-intensity assessor, particularly for newly qualified or in-training p­ ractitioners.

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From the supervision and university marking that I have undertaken in more recent years, there was a general sense of there being common anxiety to frame the wide range of normal human emotions within a five-area conceptualisation as either fear or sadness, ironically on the basis that “low-intensity practitioners do not focus on emotions.” Whilst rationally speaking, both anger and rage are as equally important as any other human emotion, it is only passive regulated anger (irritability and agitation) linked to depression that is more often than not deemed suitable for low-intensity intervention. This is not by any means to imply that anger or rage is specific to people living in low-income demographics, I am sure most therapists would agree that many of the patients they will work with who present on a spectrum of deprivation to affluence hold varying degrees of rage and complex emotional processes once they begin to scratch the surface, this has certainly been my experience working in tier-four services. But anger problems and requests for anger management were typically more common in my low-intensity assessment clinics in deprived areas and for people whose contexts included fixed and externally maintained difficulties such as unstable employment, including zero hours’ contract work, housing or neighbourhood problems, often igniting or exacerbating prior mental health problems, increasing pressure on their relationships at home and in turn, their anger and reactivity.

Anger and IAPT At the time of writing in 2022, IAPT services are not typically commissioned to work with anger as a primary problem, and where people describe explicit externalising of rage (punching doors, walls, or people), it is common here for them to be referred on to the local charity sector for anger management. During my time working in traditional IAPT services, I had little awareness that anger management (mostly group work) is aimed at people who wish to learn to regulate anger, but where someone is able to control their impulse to act out in rage. Essentially, similar criteria to IAPT services, yet thirdsector and charitable organisations that do specifically offer anger management courses are often in a precarious funding position due to a lack of local resources; at the time I worked in IAPT, this was mostly related to the health and social care cutbacks due to the introduction of government austerity measures. In response to the ever-depleting options in the social care and third-sector health organisations, there was a marked change in the referral behaviour of local GPs, who became increasingly creative with their referrals to get their patients seen by me as the IAPT worker in their surgery: A recent altercation with their partner, not allowing him to see the children. Some thoughts of suicide, no plans. Has details for Andy’s Man Club. Very stressed. Refer to IAPT.

Their rationale was quite logical that provided the patient could work on their mood and anxieties or ‘[di]stress response’ this might improve their window of tolerance, lessen their reactivity, and help them to better control anger. Many of the GPs I worked with were very compassionate and caring people and quite often their hope was that by referring a patient to their local IAPT service, they would eventually be able to access exploratory therapy to better understand and resolve the deeper source of their ongoing distress.

Suitability: People vs systems However, trying to understand whether someone is experiencing situational (housing, financial, or social) problems that are maintaining psychological distress, or whether the symptoms of depression and anxiety are maintaining problems with anger can be even more confusing and harder to pull apart on top of complex social circumstances, particularly during timelimited low-intensity assessment. Carefully monitoring our own feelings and responses so as not to make less objective and emotionally fueled decisions during an assessment can also be equally difficult. The biggest challenge I found during my work with people in economically disadvantaged communities was that people would often present on a continuum of social, situational, economic, physical, and psychological factors. Compound all of this with secondary sexual problems due to the autonomic effects of medication and poor physical health, it quickly became a melting pot that, particularly where someone might present with ambivalent disclosure around risk and suicidal thoughts, often tipped the scales beyond what could be reasonably balanced in a brief psychological therapies service. Ultimately, the person-centred assessment of need hung between the balance of a common mental health problem and a complex social narrative, with only the former being treatable through stand-alone psychological intervention. This then created an ethical dilemma for me as a low-intensity practitioner in terms of managing my own personal values (wanting to offer equitable access), my personal beliefs (everyone is deserving of help), the suitability of the intervention, available time and resource of the service (often biased by my personal values and beliefs), and most importantly, the safety and efficacy of intervention for the patient. All whilst trying to avoid personal burnout as a practitioner (Fig. 4.1).

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FIG. 4.1  Diagram of interconnected needs.

Case study: Tom See Box 4.2. Box 4.2 My early experience as a low-intensity practitioner was mainly running clinics in GP surgeries in deprived areas of the North of England historically associated with high levels of social problems. Behind the scenes, there was a warm atmosphere, but it was also stressful and ran with military precision. Around 10  months into my qualified role, I encountered my first patient suicide. Having worked with them, getting to know about their family, their hopes and wishes for the future, and then seeing their name on the coroner’s board at such a young age was a profound moment. For several months after they died, I routinely checked the coroner’s board which I nicknamed The Board of Death, before the start of my clinic. The relief upon recognising none of the names allowed me to unknot the anxiety in my stomach and settle into my day of back-to-back appointments. It was one of the most challenging but also rewarding areas that I’ve worked in. Tom was in his early 40s and had a long-term health condition, a history of repeated relationship breakdowns and recurring episodes of depression. Despite long-term antidepressant medication, his fatigue, sleep problems, and anxiety had created problems with reactivity, often resulting in outbursts and threats towards coworkers, he was eventually fired and he had not worked for several years. He was currently struggling with ‘bedroom tax’ (living in a two-bedroom council house and having to pay additional money to the government for the spare room) and was sitting on a long waiting list to be rehoused to a one-bedroom apartment. I could see from his medical records that he had previously attempted to access an IAPT service on

two occasions in the past. On the first occasion, he had been signposted to an anger management group run by a local charity. The second assessment, a year later, having not attended the anger group, he had requested individual counselling, re-­ referring himself on the back of a discussion with a retired counsellor who was volunteering at the local food bank. Tom was again denied access to the IAPT service due to his main presenting problem being situational, and frustrated with the practitioner during the appointment, became angry, the practitioner had documented in his clinical notes that they had felt ‘intimidated’, recommending that Tom should not be seen alone in a one-toone setting. Tom had again been offered another referral to the anger management group run by the local charity organisation. Tom had recently changed his GP surgery and was being referred to me as the IAPT worker at the new surgery by a practice nurse, following a routine health check that was offered to all new patients when transferring to the surgery. The nurse had not read his prior IAPT notes on the system and he was booked into a one-to-one appointment. As I met Tom in the reception area, I could see that his fists were clenched and the protruding knuckles were red with recently broken skin, there was a strong smell of cannabis, he was unkempt, painfully thin and visibly sweating and shaking. On the short walk from the reception area to my consultation room, his facial expression was stern and his gaze was fixed on the floor. PWP: Hi Tom, my name is James and I’m a Psychological Well… Tom: I know what you are, I’ve done this before! Continued

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Box 4.2—cont’d PWP: Oh…okay, I know you’ve been to us before but there are a few things I need to cover regarding confidentiality before… Tom: You mean that if you think I’m going to kill someone you have to report it to the police! PWP: Well…yes, but… Tom: I remember from last time! PWP: Sure! Can I just… Tom: Don’t even know why I’m here, been to see you lot before, you’re sh*t, you never help me! PWP: (pauses) Can I ask you, Tom, what’s brought you back to see us, to see me today?

Tom: My GP told me I had to come or they’re not going to sign me off sick. PWP: Sign you off sick? The note from the nurse you saw said they were worried about your wellbeing, there’s nothing in the notes saying the GP won’t give you a sick note. Tom: It’s what they do now though, they’re b*stards, if you don’t look like you’re trying to get the help they don’t sign you off, I then have to sign on at the Job Center, I can’t stand that f**king place. PWP: I’m hearing that you do not wish to focus on employment Tom; I’m wondering what you would like my help with? Tom: My anger!

Power and prognosis During the years that I was working as a low-intensity practitioner, I was inclined towards a perspective that the less directive and flat the power dynamic between the practitioner and patient, especially when working with people who verbalise anger, the more ‘suitable’ to IAPT that the patient subjectively appears to become throughout the assessment. I’ve since been convinced of this having listened to many trainee session recordings. If a patient is talking about anger, but the practitioner is attuned to the patient, the patient is given time to express their feelings sitting underneath the anger, this typically elicits a more empathic but minimising frame by the therapist: “it sounds like you are depressed, it’s really common to feel frustrated and irritable when you are depressed.” On the other hand, the less power the patient feels they have, particularly when working with practitioners who are directive and task-focused, leaving the patient feeling that “no one listens to me,” the more likely it is to see the person defending themselves, responding aggressively. It was also common to observe in-training practitioners becoming anxious and defensive, their language quickly leaning towards verbalised red flags for service suitability, “it sounds like your main problem is anger, IAPT services don’t work with anger.” As well as distancing and passing the person on, regardless of the likely lack of suitability to another service: “have you considered the anger management group?” Reflecting back on my time with Tom, admittedly I was feeling somewhat intimidated but also conflicted. On one hand, there were already signs that he was less likely to meet the suitability criteria for the service; on the other, my options would be to refer once again to the anger management group, or to explain there was no option for any other service that could meet his request in the local area.

Assessment phase: Tom During his assessment, Tom relayed a similar scenario to the one he gave in both of his prior low-intensity assessments, alongside a vast amount of focus on problems with housing and finances. He described several instances where he turned his anger inward towards himself, narrating self-critical thoughts within the session. However, when asked to focus on the primary issue he was most concerned about, he described reactive situations where he had received letters about housing, energy arrears, or benefits claims. Previously, he had been directed towards a local organisation that helped with finance and housing, as well as two referrals to an anger management course as none of his problems were considered to be treatable as part of a low-intensity intervention protocol (Box 4.3).

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Box 4.3 Ending the first session PWP: I’m aware of the time Tom and we’ve spent a lot of time today talking about the different problems you are experiencing; I would really like us to meet up again to talk through this a little more. Tom: You mean you want to see me again? PWP: Yes, I would like to offer you another appointment so we can talk about what IAPT offers and whether you think that it will meet what you are wanting from it. Tom: I suppose, is it here though, or do I have to see someone else? PWP: It would be with me, here. Tom: Fine, I suppose so! PWP: Good! Before we book that in, the surgery team has asked me to ask you about getting you some food, would that be okay for me to ask you about it, Tom? Tom: For f**k’s sake man! I told them before, I’ve never been a scrounger, no way I’m taking handouts. I would rather starve, it’s the last bit of self-respect I’ve got left [starts to get agitated, getting up out of his seat to leave]. PWP: This is not a handout, Tom, we have an in-house foodbank, similar to the social enterprise near your house, it’s specifically for people who are at risk of ill health due to long-term health conditions. We have one here

at the surgery, reception can bring the shopping to the room for you and no one will know when you leave that you didn’t have the shopping bags with you when you came in. [Tom is still standing up but silent for a few minutes]. PWP: [warm tone] Shall I send reception a message? Tom: I just can’t stand taking hand-outs, and there’s no way I’m going to the drug service, not a chance, not with all the druggies and the judgmental faces, I ain’t no junky! PWP: I’m not asking you to go to the drug service, Tom, but I imagine you might need to eat at some point? Tom: [long pause] yeah [long pause] okay [long pause] message them! [The receptionist is an older woman, she knocks on the door and hands three full bags of groceries to Tom and puts her arm around him]. Receptionist: I’ve put you an extra packet of biscuits in there my love, I hope you enjoy them. [Tom’s eyes are filled with tears but he is trying to stop himself from crying]. PWP: I will see you in a couple of weeks; I hope you’re feeling okay about the shopping? Tom: [suppressing tears, and halfway out of the door] Whatever!

One of the difficulties of working as a low-intensity practitioner in an IAPT service is that practitioners are often navigating competing demands: time, patient needs, access, and outcome targets. At a very practical level, they are often too pressured during short appointments to spend the time filtering the background context sufficiently to uncover what the maintaining factors of anxiety and depression are. Ultimately, this can lead to inadequate case conceptualisation and, as a consequence, a poor person to intervention match. Whilst I might reflect more deeply on the interpersonal dynamics in my work now, at the time of my work with Tom, I had neither the training nor supervision to be able to pull this apart. Admittedly, the work set off in less-than-ideal circumstances. Within the first 10 min of the session, I had already begun ruling him out of low-intensity intervention but was also concerned about him. By the end of the session I had offered another appointment, mostly to buy me some thinking time and to discuss his case under supervision, but by doing this had not fully considered the expectation that I might be setting for Tom.

Second assessment session (treatment session one) During Tom’s second (extended assessment) session, we picked up where we had left off and developed a second five areas model based on what happened immediately after the reactive situation that had been described (Fig. 4.2). At first glance, this may look like a partial utilisation of the ‘downward arrow’ technique typically used within high-intensity CBT, see Kennerley et al. (2016, pp. 164–167). In this instance, it was not being used to dig down underneath automatic thoughts to reveal rules, assumptions, or core beliefs; instead, it was being used to dig through the outer surface layer of his social context. Rather than simply asking Tom what he could do differently when he experiences rage, I simply asked him how he felt after smashing up his phone. What I now had were the automatic thoughts, feelings, and behavioural cycle in the here and now that featured in Tom’s more stable experience of depression, as opposed to his experience of reactive distress when receiving a letter from a government agency.

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FIG. 4.2  Five areas formulation. The initial five-area formulation of Tom’s initial description of his problem at his first appointment followed by his more stable experience of self-criticism, maintaining depression. (Adapted from Greenberger, D., Padesky, C.A., 2015. Mind Over Mood: Change How You Feel by Changing the Way You Think. Guilford Publications.)

Complicated maintaining factors: Barriers to change There are also differences between a person already having underlying problems with depression and anxiety that are exacerbated by their social contexts, and people who are experiencing anxiety and depressive symptoms as a direct result of their social contexts (Elliot, 2016). Imagine you have lived happily in the same house for 10 years and 1 day new neighbours move in next door, after a few weeks, you suspect they are dealing drugs. Whilst you are taking your children to school you bump into another neighbour who tells you that they had recently had their home invaded by a gang who threatened them with a gun. After the police



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had investigated the incident, they concluded that the gang had broken into the wrong house, intending this to be your new neighbour’s property who you suspected of drug dealing. The neighbour whose house was broken into then tells you that they have since been approached by your new neighbours and were threatened by them, told they would be hurt if they were to have any further contact with the police. How would you feel? Let’s say you started to worry about bumping into your new neighbours, or not feeling safe sleeping at night with your children in the house. Eventually, this develops into panic attacks when you think about leaving your home, letting your children play in the back garden, or going to sleep at night. To manage this, you approach your GP surgery for medication to help you sleep. The GP, concerned about the potential for dependency on sleep medication, then refers you to an IAPT service to help you with anxiety and sleep. It’s quite reasonable to ask the question here as to whether psychological therapy is going to be either viable or ethical for you to engage in. For example, CBT-based therapy often targets unhelpful or distorted thinking and maladaptive behaviour. If you are living in fear as to the possibility that you might be caught in the crosshairs of a rival drug gang, unable to do anything about it without the potential of being hurt, it would be neither practical nor ethical to suggest that your thoughts were illogical or irrational. Nor would it be helpful to consider your avoidance of the new neighbours to be maladaptive. In fact, it is possibly the safest course of action for you given your social context, unless you have alternative accommodation. After a further month of rarely leaving your home or sleeping, you start to develop symptoms of depression. Again, based on your immediate social context, the solution to the problem around being able to return to the normality of the routine you once had depends on external factors (safety concerns relating to your neighbours). The solution to remedy the symptoms of both anxiety and low mood would lie within change being outside of your thoughts and behaviours, in favour of practical changes that are currently outside of your control. For example, the drug-dealing neighbours moving out, the police arresting them, or the local residents’ association reporting the issue to the local authorities. Therefore, a psychological intervention focused on what you are thinking or doing is likely to be ineffective, given the maintaining problem lies in what is external to you. My experience when working with people living in particularly problematic areas with high levels of crime and antisocial behaviour was that these contexts could change week by week and present in addition to underlying chronic problems with ill health, anxiety, and depression. Essentially, the person’s social context would rarely map very neatly onto the monitoring of reliable changes in anxiety and depression symptoms through quantitative outcome measures, namely, the PHQ-9 and GAD-7. Some practitioners might consider offering tools and techniques to help the person manage or tolerate the distress stemming from truly situational problems, such as relaxation, mindfulness, or worry management-based techniques. Potentially all three might be helpful to a degree, we have seen similar offers to the general public around managing distress in relation to the fixed and uncertain challenges of the Covid-19 pandemic, but what we would be delivering here are temporary coping strategies for the effects of an external context rather than individual psychological intervention (therapy). Therefore, it is unlikely to offer any long-term relief whilst the primary source of a problem that maintains the symptoms, persists. Equally, we would not be expecting the symptoms associated with anxiety and depression to fully abate if the maintaining source of the problem is outside of the person’s control. Whether this relates to problematic neighbours, unstable employment, or navigating the world within the context of a highly infectious deadly virus with unpredictable outcomes, those who have preexisting difficulties with depression and anxiety, may also see their symptoms increase. An example here, within the context of Covid-19, was where people were experiencing worsening depression because their typical coping strategies such as using the gym or visiting friends and family had been curtailed by the restrictions dictated by social distancing. What we might be offering here are ­psychological interventions and education more focused on ‘functional equivalence’, for example, attempting to limit the symptoms of low mood through compromised change, where this is possible for the patient. For example, sleep hygiene and moderate exercise or activity. However, what we would not be expecting is a ‘recovery’ to full psychological health or ‘normal’ functioning until the crises or the environmental problem resolves.

Dissociated systems The IAPT programme at a national level talk a lot about inclusion and the IAPT Manual (NCCMH, 2021) offers a comprehensive guide for local services. Where services are pressured to meet the outcome targets aimed at the statistical mean of patients who are required to flow through the IAPT programme to maintain accessibility, due to waiting times, recovery targets, national service monitoring, and localised commissioning, this can lead to a risk of incentivising numerical outcomes over pragmatic, flexible, and adaptive approaches to meet the needs of those who are disadvantaged in our local communities. The result here becomes a systemic dissociation from the real-world application of low-intensity intervention leading to depersonalisation in clinical practice. The evaluation of practitioner performance, linked to their annual appraisal (Fig. 4.3), becomes guided by the anxiety for numerical output as opposed to making a real-world difference.

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FIG. 4.3  Detached systems and impact of targets on patient care.

For low-intensity practitioners, when it comes to shaping low-intensity interventions to include the experiences of people who face continuous social adversity, innovative, adaptive, and creative practice comes at a human cost. As a lowintensity practitioner, I rarely engaged with textbook patients and rarely delivered textbook intervention. The lived reality was often that in order to make a real-world difference for patients who deviated from the mean, whilst also attempting to maintain the national standards on outcomes (linked to service funding), this came at the expense of the patients and the wellbeing of the low-intensity workforce; this is covered in more detail in Chapter 7, Staff Wellbeing.

Motivation for change During the second assessment session with Tom, I assessed his motivation for change, asking him about the barriers to attending the group work that he had been offered previously. Tom did tentatively express to the practitioner that he would not feel comfortable talking about his problems to a group of strangers, particularly if there were other men there. The practitioner had told him “group work is typically psycho-educational, it’s not a therapy group, you won’t have to speak,” to which Tom had thought “so what’s the point then?” He felt as though he was constantly being turned away for help when he asked for it and began isolating himself socially. Tom had encountered something I often witnessed in both my own clinical practice and also cases brought to me as a clinical supervisor, in that his explanation of his problem did not match that of a neat and tidy formulation that met the standard IAPT service criteria, and reflecting back now, was more typical of the presentations I would normally see in a secondary care Community Mental Health Team (CMHT), albeit Tom presented with lower risk. Whilst no one had previously spent sufficient time with him to fully understand what was sitting a little further underneath the surface, this was also not the model of low-intensity therapy and is not a criticism of the low-intensity practitioners who had seen him previously. They were in fact more adherent to the model than I. But for me, the offer of extended assessment came under reasonable adjustment based on what we knew (as a team) from our subjective experiences of being embedded within the GP surgeries in this local area. The reality is that no therapist or amount of therapy would be able to solve all of the problems that people commonly presented with in relation to social care needs, but for Tom, we had the potential to start with small steps to help him begin to understand the surface level cycle in his depression. The only other available option at the time, given he met neither the threshold for social care or secondary care mental health services, would be to re-signpost him to another anger management group. I contracted with Tom that we would fo-



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cus the initial sessions on developing a mutually agreed problem statement, what are we in agreement that we are working on? It took a further two sessions to narrow this down to his personal wish to improve his basic routine of eating, bathing, and cleaning his home. What was hard to gauge from this, given that the appointments were undertaken in the GP surgery, was that the extent of his difficulties at home was likely not fully disclosed. Whilst digital-enabled therapy such as video therapy can often limit access for those who cannot afford internet connection and technology, where this has been possible, I have in many cases been able to observe someone’s home environment which has given me far greater information than working from the GP surgery. However, my work with Tom was prior to the pandemic and was not something the service offered at the time.

The human story of anger and shame During his fifth session, Tom talked about his prior feelings of rejection from his initial interactions with the IAPT service. After the second attempt, Tom had given up on psychological therapy and decided to take his GP up on the offer of a new antidepressant medication. He then began experiencing problems with erections as a side effect of the medication. He ­interpreted this as yet another failure of self and was too embarrassed to tell anyone about it, not even his GP. What hope did he now have of building another relationship? It took several sessions of Tom and I working together to build the trust to tell me about the problems he was having with erections, and it was actually me who broached the subject, reading between the lines. Once I had made Tom aware that erectile dysfunction can be a common side-effect, Tom re-booked a review with the GP and his medication was changed, which resolved the problem. What Tom was learning throughout his experience in this new GP surgery (aside from a very loosely adhered protocol for behavioural activation) was that he could talk about a problem, and someone would listen to him, take his concern seriously, and give him an honest take on it. He also learned that he could (to a degree) begin to trust a little more in the information being given and could make choices based on this but also helped him to discriminate between problems that could or could not be solved on his own.

Difficulty containing disclosure Amongst the bite-size snippets of Tom’s story that I attempted to contain during each session, reflecting back, his interpersonal problems made a lot of sense in terms of his history. As a low-intensity practitioner at the time, I was neither qualified nor trained to explore the content of the material he disclosed and his disclosure was often random and not necessarily in keeping with what we were talking about. We might be focused on problem-solving a specific task during the session, where Tom was struggling to motivate himself to make changes. Tom might respond with, ‘I used to spend a lot of time outside walking, my step dad was a [insert choice of expletive]’. Or, he would briefly talk about childhood memories and return to the task as if his disclosure had never happened. Essentially, his disclosures were hard to contain, because there was often no lead-up to them and he immediately detached from them. I simply managed this by offering a validating statement, balancing avoidance of opening exploratory discussion, but trying not to be dismissive at the same time, all whilst holding onto my strong pull to dig and explore. Throughout the entirety of our work together, Tom revealed that at the age of 6 years old, his biological father died by suicide, Tom had found him hanging on the back of the kitchen door early one morning. Aged 7 years old, Tom’s mother entered a violent relationship and he witnessed her being beaten repeatedly. As he grew older, the rage of his stepfather was directed at Tom. Aged 11, he returned from school with mud on his shirt, having been in a fight with another boy, teased for his dyslexia. His stepfather was so enraged that he pinned Tom to the floor face down in the living room, kneeling on his legs and repeatedly punched him in his back, causing Tom to urinate through fear. His mother quietly withdrew from the room saying “you need to be more careful with your clothes.” His stepfather then beat him until he passed out. He was kicked out of the family home aged 16 because he was struggling to get a job due to anxiety and therefore not contributing financially, “a burden to your mother!” The relationship with his mother remained distant ever since. If we consider Tom’s case in terms of the age that he experienced trauma, neglect, and violence, his experience in the here and now made absolute sense (Fig. 4.4). However, I could not help him connect the dots, due to the limitations of my training and the role, but it also made sense that the psychological education I would give relating to depression (reduced activity leading to lower mood), naturally fell awkwardly on his ears. Equally, stepping up to high-intensity CBT or brief counselling in an IAPT service might also likely have been difficult to fully explore his history, particularly given the lack of stability in his social context, and especially if focusing on traumatic memories. Certainly in LICBT, any potential of trying to make shifts in his thoughts through low-intensity cognitive restructuring would very likely come up against egosyntonic processes and core beliefs (Box 4.4).

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FIG. 4.4  Tom’s early experience as an influencing factor across the five areas in the here and now.

Box 4.4 I saw Tom for a total of nine sessions with multiple barriers to engagement. Sessions were very briefly related to why Tom didn’t feel able to go for a daily walk; this was due to him owing his drug dealer money and not wanting to be seen. We attempted to problem solve how he would negotiate payment instalments, to leave him safe to walk the streets. Each session elicited more of Tom’s context. Each foothold we secured for the work began to crumble under the weight of more complex social factors. Each week I saw Tom for an appointment, we drifted beyond the remit of low-intensity psychological therapy towards more of a social support worker role. As we progressed, there were some unintended beneficial consequences in that Tom had reported a significant reduction in his cannabis use of his own accord and although we never directly focused on his problems with anger, he was no longer punching his living room door and his new phone was still intact. At his penultimate appointment, he was thinking about applying for a job and I referred him to an employment skills

coach. Tom did not attend the employment coach appointment stating that it was “early days” and he wanted “to see how he went on.” His measures of psychological distress had shifted somewhat, with depression (PHQ-9) reducing from 23/27 to 14/27 and his measures of generalised anxiety (GAD-7) reducing from 21/21 to 16/21 since his first session. He was not experiencing thoughts of suicide or self-harm and had more recently attended his sessions clean-shaven and wearing fresh clothing, having started a friendship with another tenant in his new flat who was helping him out with domestic chores. From both an objective and subjective standpoint things appeared to be going a little better for Tom. Whether LICBT was the facilitator of that I am not entirely sure. He told me that he had learned some useful things from our sessions but felt the work had become repetitive, “I’ve told you everything I wanted to tell you” and did not feel ready or willing to engage with higher-intensity therapy. We were both reasonably happy with the progress he had made, Tom agreed

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Box 4.4—cont’d to me making a referral to a local charity that offered community engagement and support, and I invited Tom to return to the IAPT service (and documented this in his medical notes) should he wish to access the service again in the future. Ending treatment: PWP: I would really be interested to hear how you found the sessions, Tom. Tom: It’s not been as bad as I thought. PWP: What did you think would be bad? Tom: [laughs], I just thought you were a bit of a prick at first, no offence. PWP: I’m glad I was less of a prick than you thought, I guess that’s a win? Tom: [looks concerned], oh, oh, no, I didn’t mean, y’know, I mean you’re alright, y’ know. PWP: What have you found the most useful from the sessions? Tom: [avoids eye contact] It was ‘down there’ [pointing to his groin] making me smash the f**king place up. You helped me with the doctors and that… [Tom’s demeanour quickly shifts. Shoulders back, chest puffed out, legs apart in the chair]. PWP: I’m really glad that helped Tom, it’s a common thing that can really impact, we don’t talk about it enough. Tom: [aggressive tone] Well I’m hoping I don’t see your mugshot again pal, no offence! PWP: As long as you know that you are welcome to come back if you need to in the future. Tom: Yeah, whatever! [walks out of the room]. During the year that followed Tom’s discharge, I saw many more people in similar situations. Numerous conflicted discus-

sions with the GPs around service suitability, countless assessments for people where their problems were not readily treatable with psychological intervention and endless streams of people who had booked appointments but never attended. Equally, the pressure and continuous hearing of stories of distress with no formal outlet to debrief from difficult sessions due to the time limits and constraints of low-intensity supervision, I ploughed on, ebbing and flowing on my own personal scores on the PHQ-9 and GAD-7. In the following January, I returned to the surgery after the Christmas break, unlocked my room, made my coffee, chatted to some of the staff catching up after their holidays, and helped myself to leftover Christmas cake brought in by one of the practice nurses. I looked up from the cake on the table and saw Tom’s name on The Board of Death. I had ten patients booked in throughout the day, eight turned up, each had a distressing story, a husband that had told his wife he had been having an affair on Boxing day and was sleeping on his friend’s sofa, a lady who was worried about losing her home after spending her rent money on the kids presents, a health worker stabbed over a parking space whilst supporting a patient on New Year’s eve, still freshly bandaged, and three people who experienced bereavement just before the Christmas period. At lunchtime, I opted to leave my usual note writing and spoke to the practice team about Tom. His death, whilst not determined to be suicide, was most likely related to the complications of his physical health and severe selfneglect. Similar to his case falling between the gaps in service criteria, his death fell between the cracks of social neglect and self-harm. There was no practitioner protocol or manual to explore my feelings about that.

Reflecting on Tom’s case My reflection on the main area of change for Tom was actually being attuned to him enough to read between the lines, offering psychological education about erectile dysfunction. Otherwise, his motivation for engagement in psychological therapy was quite low. In terms of the changes outside of sessions during his low-intensity treatment episode, I would attribute this to being more likely related to moving to his new flat and having support and friendship from his new neighbour. Sadly, I cannot know what happened in the year following his discharge as he did not engage with professional services beyond that point. It is possible the neighbour moved, perhaps he started a sexual relationship that ended due to a recurrence of erectile problems, another episode of severe depression, leading to physical health deterioration through neglecting and dismissing his needs, or simply bad genetics, there could be endless possibilities. The bottom line is that what happened to Tom, including in his earlier life, was both tragic and incredibly sad. Ideally, Tom would have accessed the community support charity he was referred to, someone able to regularly check on his home and his wellbeing. Yet, it is also possible that he may not have accepted the offer of help. Whilst low-intensity psychological intervention is aimed at relatively healthier individuals presenting with mild to moderate problems, maintaining fidelity to the manualised protocols of LICBT could often feel impractical, poorly fitting and at times utterly impossible to apply when working within real-world social contexts; at least when it was not applied flexibly. Having worked with many people like Tom over the years, once the interpersonal barriers have eased over a few sessions then this is the point where deeper assessment begins. Adaptations can be made, spending some time hearing their story, and trying to identify where and why a low-intensity intervention may be possible. Undertaking a thorough person-centred assessment of need from the unique human in front of you is what we should be offering at the very least, and should form

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part of our ongoing assessment throughout the entire treatment episode. We cannot simply decide on a specific intervention at the start and plough on regardless despite new information that contradicts our service-mandated protocol and process. It is our responsibility as clinicians to be as attentive to our own need for change as we would expect our patients to be. The main challenge is limited time and the sheer volume of people seen in low-intensity clinics that require some element of give within the process or suffer empathy fatigue, detachment, and burnout.

Adaptations and flexibility Whilst the low-intensity practitioner role is mainly educational and technique based, the conditions created by both the patient and the practitioner are equally (if not more) important as any intervention we deliver. Our patients may not present with years of training or knowledge around cognitive and behavioural cycles, but they still possess the ability to read body language, and vocal tone, intuitively navigating whether you are truly hearing them, interested in them, or judging them, and for some, this will be their experience even if you are truly listening and taking a nonjudgmental stance. The key here is that the practitioner has self-awareness and can hold the feelings and experiences of the patient they meet in the therapy room. Particularly for people who experience deep shame about their contexts whether current or historical, express anger, or disclose alcohol and substance use, we must tread with careful curiosity rather than prescription in terms of how we respond, particularly how popular theories of depression and anxiety might feel minimising or dismissive, without fully knowing how the person came to be where they are at. Where someone’s prior experiences of relationships were fragile or traumatic, we must not underestimate the corrective experience of basic human kindness and compassion, sometimes this is hard when the person expresses anger or contempt, but as with the case of Tom, where people who have experienced severe abuse and emotional neglect in their early life, this is often their generalised expectation from others. Compassion and care can then generate complex feelings, eliciting both anxiety and anger, demonstrated in the complex feelings generated for Tom towards me when we ended our final session. The main tool I had in terms of managing this was simply to notice the feelings being generated for me and to manage my therapeutic response, in this case to offer a consistent offer of care. Yet, the visceral experience that Tom encountered when he received his groceries from the GP receptionist was not part of any LICBT protocol, nor does it appear in any high-intensity training manual. But I would argue that the simple offer and acceptance of human care and kindness were more powerful in helping Tom temporarily shift his beliefs than any LICBT workbook that I could offer him. It is also not unusual for seasoned practitioners to adapt and blur the boundaries of their intervention roles in favour of talking practically around interventions and demonstrating in session modelling, rather than form filling and setting reading as homework, provided that they are still basing their work on the change method of CBT, and are not attempting to deliver interventions outside of the scope of their training. Traumatic histories, difficult relationships, and problems with anger should not be an automatic exclusion to an offer of low-intensity work. Granted, it takes a lot of human skills, empathic curiosity, and reflection to help someone filter the background context enough to identify where LICBT is likely to help. It can also be challenging for both the clinician and the patient to mutually contract around the containment of the sessions. Equally, each clinician will have their own style or way of doing this. My personal approach (and have carried this through into the work I do now) was to simply be realistic about the expectations of an approach and to offer the patient choice, where possible, and with integrity.

Core conditions Essentially these form part of the core skills in any helping relationship, from support workers, specialist psychotherapists, and physical health workers, to hairstylists, bartenders, and customer service representatives. Low-intensity practitioners use common human skills with practical problem-solving abilities. Not using a model to unpick and reflect on childhood, or activated schemas, or intellectual formulation of defences (albeit still intuitively felt). Tom, like many of the patients who present to mental health services, didn’t necessarily want [T]herapy but did want to tell his story. What he intuitively wanted didn’t immediately fit the low-intensity CBT model, but low-intensity practice did meet him (to a degree) where he was at. The clinical reality is that much of the work undertaken by a low-intensity practitioner is loosely held, negotiating and compromising to meet a patient’s needs rather than purely delivering health technology, or at least delivering it in a way that we are taught in postgraduate training courses. Certainly, for the local demographic I have described within this chapter, IAPT would literally have a handful of treatment patients if we did this by the textbook.



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Problems in supervision Equally, how patient engagement is discussed in case supervision can also create narratives that perpetuate barriers. I have attended countless group skills and clinical supervisions where I’ve heard low-intensity practitioners talk about patients “not doing homework,” or “just wanting to talk,” and this being a reason for discharging them. In the areas that I mainly worked, I rarely did anything that would resemble textbook LICBT, rather human-to-human contact, frank discussion, validation, and a nonjudgmental and empathic relationship. The delivery of basic CBT-based change method principles alongside that, at a pace and direction that someone could manage.

Informed care So what do we do when there is no other service available and the person is asking for help with a problem that is unlikely to be treated with low-intensity intervention? In some cases, particularly where someone is most likely requiring multidisciplinary input, offering LICBT as something is not in every case necessarily better than nothing. This may sound odd given the depth of experience I have relayed within the chapter. Whilst offering nothing can feel incredibly rejecting, potentially fueling messages of being ‘unworthy’, entering into an intervention that has a low likelihood of success or dismisses the core problem, can be equally damaging. We can also run the risk of plugging gaps within the system and by doing so metaphorically pasting over the cracks. The dilemma here often is that people inevitably suffer as a result whilst waiting for the pressure within those gaps to reach a point where it can be seen. Wherever possible we need to offer a space in our assessments where we can properly hear what the person is saying, regardless of the service the person presents to; an approach that is validating and where the person is in the driving seat in terms of the clinical decision-making process around their care following that assessment. This is likely to take more time than 45 min, particularly where someone experiences a complicated social context. In terms of low-intensity intervention, provided that there is explicit contracting and mutual agreement to support someone within the scope and knowledge of the practitioner’s training, and that this can be done transparently to work on the symptoms of anxiety and depression, I think it is fair to suggest that there is generally an opportunity to learn symptom management, regardless of someone’s social context or diagnostic status. Yet, where the person is motivated to address more in-depth exploration or requires a longer term, or multidisciplinary approach, beyond the knowledge, scope and training of the low-intensity practitioner, then attempting to undertake this work simply because there is no other service available, would not be ethical. There will likely be clinicians who disagree and like any human interaction, each of us will approach our work differently. Equally, how these conversations land with patients will also differ and explaining to someone that their request for assistance is likely to take a substantial amount of time, will involve them repeating themselves again, and will not guarantee they will be seen, in some cases they will not be seen at all, is messy. One of the biggest challenges is sitting (as a clinician) with the discomfort of those discussions, particularly when the person is desperate for help. It is far easier for us to pass the person on, or make promises without any substantial basis, simply to ease the transaction; in some cases, this can be as much about managing difficult feelings for the clinician, as it is about managing the expectations for the patient. I speak here from personal experience as someone who wrote endless amounts of referrals to secondary and specialist psychology services on the back of two low-intensity appointments, adamant I could help everyone that came through my door by doing so. Despite our best intentions, this is neither possible nor realistic. Since working on the other side of the fence in tier four services where someone has waited upward of 2 years for psychotherapy, it is not uncommon that the patients arrive and are (a) ambivalent about therapy, (b) do not attend, or (c) have significant barriers to tolerating trauma-focused work due to significant risk, excessive alcohol and substance use, or problematic home life and social contexts. Essentially, what I am saying here is that the assessment of need and decision-making when a patient approaches any psychological service (regardless of which service) needs to be as realistic and collaborative as it would be in an IAPT service, it is simply the range of modality and length of approach that can differ. Otherwise, we run the risk of patients being passed around like a hot potato and leaving them unnecessarily waiting for services that may not actually be able to offer any more help with their problem than the IAPT service could, including anger management groups. That is not to say that we should not be referring people where appropriate.

Neglecting and dismissing our own needs as clinicians It is also vitally important given the challenges that we will face in low-intensity practice that we can look after ourselves. Whilst the service where I spent the majority of my low-intensity practice had a high threshold for working with dynamic

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risk factors, at the time. They would also offer swift support in the event of crisis and the management team was immediately on hand during difficult cases, particularly where this involved a patient death. After Tom’s death, I was offered access to the staff wellbeing service, and additional time to prepare and reflect before writing my coroner’s report, including additional supervision if I needed it. My response was “I am fine” it was “part of the job,” shrugging off any offer of support in pursuit of “managing by myself.” And, albeit at a more implicit level, engaging with my own unconscious process of dismissing and ignoring my own needs, instead, applying more pressure on myself, “there are too many patients waiting, I cannot take time off.” My capacity for self-compassion was slim, my main emotion was anger, but I had sufficient early modelling to contain it. Instead of punching doors and walls, I complained to coworkers about how “rubbish” the low-intensity role was, and the “terrible” health and social care system. Rather than accepting the support available, the advice of my peers, and supervisors, and nurturing my basic human need to be sad at the situation, I simply told myself that there would be many more Tom’s, never enough social support, never enough time to assess, so what was the point in taking time off and crying about it all? I detached from my emotions, opened a bottle of wine at home, and started fresh in another clinic the next day. And repeat.

Reflective exercise ● ● ● ● ● ●

Can you recall a specific case where you have encountered a patient with a challenging social context? Thinking back to this case now, would you have done anything differently? How did the case impact you emotionally? Did you have support offered, or was this available when you were dealing with this case? How did you look after yourself at the time? Would/could you have done anything differently to look after yourself?

References American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, fifth ed. American Psychiatric Association, Arlington, VA. Appleby, L., Hunt, I.M., Kapur, N., 2017. New policy and evidence on suicide prevention. Lancet Psychiatry 4 (9), 658–660. Clark, D.M., Canvin, L., Green, J., Layard, R., Pilling, S., Janecka, M., 2018. Transparency about the outcomes of mental health services (IAPT approach): an analysis of public data. Lancet 391 (10121), 679–686. Elliot, I., 2016. Poverty and Mental Health: A Review to Inform the Joseph Rowntree Foundation’s Anti-Poverty Strategy. Mental Health Foundation, London. Finegan, M., Firth, N., Delgadillo, J., 2020. Adverse impact of neighbourhood socioeconomic deprivation on psychological treatment outcomes: the role of area-level income and crime. Psychother. Res. 30 (4), 546–554. Kennerley, H., Kirk, J., Westbrook, D., 2016. An Introduction to Cognitive Behaviour Therapy: Skills and Applications. Sage. Knifton, L., Inglis, G., 2020. Poverty and mental health: policy, practice and research implications. BJPsych. Bull. 44 (5), 193–196. Kroenke, K., Spitzer, R.L., Williams, J.B., 2001. The PHQ-9: validity of a brief depression severity measure. J. Gen. Intern. Med. 16 (9), 606–613. National Collaborating Centre for Mental Health, 2021. The Improving Access to Psychological Therapies Manual. Available at: https://www.england. nhs.uk/wp-content/uploads/2018/06/the-iapt-manual-v5.pdf. Self, R., Shin, R.Q., Woates, P., Pinnock Hamilton, T., Leach, C., 2005. The relationship between social deprivation and unilateral termination (attrition) from psychotherapy at various stages of the health care pathway. Psychol. Psychother. Theory Res. Pract. 78 (1), 95–111. Spitzer, R.L., Kroenke, K., Williams, J.B., Löwe, B., 2006. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch. Intern. Med. 166 (10), 1092–1097. World Health Organization, 1992. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. World Health Organization.

Chapter 5

The role of low-intensity psychological interventions in physical healthcare Elizabeth Ruth University of Bradford, Bradford, United Kingdom

In this chapter The interaction between physical and mental healthcare is a complex and sometimes controversial subject so I will start this chapter with a disclaimer. I am not a medical or physical healthcare professional; it is not my intention to give medical advice. I will not even have the scope to explore the entirety of the interaction between low-intensity psychological interventions and physical healthcare. This chapter will: ● ● ●

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Illustrate the potential of low-intensity psychological therapies when they are integrated into physical healthcare pathways; Capture some of the experience of what it is like to live with long-term health problems; Explore how low-intensity psychological interventions might be used in physical healthcare settings to support patients to acquire the skills to effectively manage their physical and mental health to live the best possible quality of life in the presence of persistent illness; Acknowledge the dynamic and expanding role of low-intensity psychological interventions using work with long-term conditions as an example.

This chapter offers a small space to cover a very large subject; I can’t do justice to all of the work in this area of speciality here. To manage the constraints of our word limit, I have kept a focus on the work that I have had the opportunity to observe locally and work that I have participated in. This is to provide examples of what can be done with low-intensity interventions in the context of physical ill health, not to suggest that this is all that can be done. The chapter will be arranged into three parts: Part 1: Defining terms and providing background information. Part 2: Identifying themes in this area of work. Part 3: Ideas that are relevant to the implementation of low-intensity psychological interventions in the overlap with physical health.

Part 1: Defining terms and background information Long-term health conditions: Context and considerations In 2002, the World Health Organisation (World Health Organization., 2002) recognised chronic physical health conditions as the great challenge of the 21st Century. Healthcare systems around the world are challenged to manage the care of billions of people who live with ongoing, currently incurable, physical health conditions. Most of us will know someone who has been diagnosed with a long-term condition that might be ● ● ● ● ● ● ● ●

diabetes (of any type); a heart condition like heart failure or angina; dermatological conditions like psoriasis and eczema; a musculoskeletal disorder like arthritis; a respiratory disease like chronic obstructive pulmonary disease (COPD) or asthma; a neurological disease like epilepsy, Parkinson’s disease, or multiple sclerosis (MS); organ failure; a gastrointestinal disease like Crohn’s or Colitis.

Care in High Volume. https://doi.org/10.1016/B978-0-323-88492-1.00005-1 Copyright © 2023 Elsevier Inc. All rights reserved.

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These examples are all ‘long-term health conditions’, what I will refer to as ‘LTC’ from now on, where the disease processes—the changes that have occurred in the body to produce the symptoms—are identifiable and fairly well understood by medical science. Although the disease is identified and understood, none of these conditions can currently be cured and have to be managed with a combination of medical support and self-management. Although these conditions affect the risk of depression and anxiety—more about that later—there is no suggestion that a psychological treatment would make any difference to the disease process.

Medically unexplained symptoms Another type of health experience occurs when somebody loses their health—they experience physical symptoms that impair their activity and reduce their quality of life—but these symptoms and physical changes are not yet explained or well understood by medical science. Sometimes referred to as a ‘diagnosis of exclusion’ patients are typically tested for the known disease processes that might cause the symptoms that they describe, and once these have been ruled out, then presented with either no diagnosis or one of the labels in the next paragraph. This process can at least assure patients that any possible ‘sinister’ (potentially fatal) causes for their symptoms have been ruled out. These conditions are often referred to as ‘medically unexplained symptoms’ (MUS) or ‘persistent physical symptoms’ (PPS) or ‘somatic symptom disorder’ in the academic literature and on websites like the NHS patient information pages. Syndromes (collections of symptoms that often occur together) that often fall under the ‘MUS/PPS’ umbrella in the literature include ● ● ● ● ● ● ●

Irritable bowel syndrome (IBS); Myalgic encephalomyelitis (ME); Chronic fatigue syndrome (CFS); Postural tachycardia syndrome (POTS); Many examples of chronic back pain and joint pain; Fibromyalgia; Functional neurological disorders (FND), including nonepileptic attack disorder (NEAD).

Someone who is living with these clusters of persistent physical changes might experience symptoms of chronic pain, crippling fatigue, dysautonomia (problems with the parts of the nervous system that control involuntary physical activity like heart rate and digestion), gastric symptoms, and cognitive impairments amongst other experiences. These patients often do not have the option of medical management—there are no prescription medications to affect the as-yet unidentified disease process—and are often required to intuit effective self-management of their health. These clusters of experience sit more obviously in the uncomfortable cross-over between the mind and body where psychological therapy can sometimes provide some relief from primary symptoms or secondary distress. For example, intensive short-term dynamic psychotherapy (ISTDP) has been found to reduce the severity of symptoms of some functional somatic disorders and, in some cases, eliminate them (Abbas et al., 2021). Within the IAPT programme, several syndromes have been dismissed as psychosocial conditions (NCCMH, 2021)—with the assumption that the disease process has not been identified because there isn’t one—to the detriment of patient care (Geraghty and Scott, 2020). There is a growing trend in England to approach the chronic postviral sequelae of COVID-19 (long COVID, postacute coronavirus disease) as a ‘functional’ diagnosis, mirroring the treatment of other postviral conditions. Other healthcare systems have the scope to acknowledge the complexity of the overlapping systems within the body and can acknowledge the role of stress and psychological and social elements of health, without dismissing the physical elements of a condition or syndrome (Gilio et al., 2021). Because of the global onset of this particular postviral syndrome, England’s trend of offering predominantly psychological ‘treatment’ for unexplained physical symptoms is balanced by bio-medical research initiatives around the globe. Meanwhile, IAPT services, often involving their low-intensity practitioners, were quick to expand their long-term conditions offer to include the ‘Long COVID’ diagnosis.

In my experience, when a person is living with long-term physical health symptoms, the symptoms are real to the patient, whether the aetiology has been pinned down or not. In this chapter, I will use language that reflects this; MUS and PPS symptoms will be included in the ‘LTC’ descriptor unless I specifically state otherwise. This is not in keeping with the rest of the literature on this subject. What we can offer as low-intensity psychological practitioners doesn’t change if someone’s health condition is considered to be an LTC or comes under the MUS umbrella, our job is to support effective condition self-­management and reduce symptoms of depression and anxiety to enable people to meet their goals, not cure a health condition. Continued

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Whether medically explained or not, the symptoms of an LTC can be so severe that it is not possible to complete even essential self-care like preparing a meal; some people have symptoms so severe that they are no longer able to work, socialise, or engage with their hobbies. Patients who live with incurable changes to their health are at risk of reduced quality of life and are significantly more likely to experience depression and anxiety disorders than someone who is physically well. That risk is even higher if the physical changes are medically unexplained.

Terms used in this chapter Allied health professional: Healthcare professionals who are qualified in a profession related to physical or mental health. These are usually practitioners with degree level training and are professionally autonomous practitioners who are usually regulated by the Health and Care Professions Council in England. The bio-psycho-social model: The biopsychosocial model or approach was proposed by Engel in 1960 as a means of unifying and mitigating against the excesses of the polarised views of the medical model and psychotherapeutic approaches in psychiatry. It attempted to move away from the biological reductionism of the medical approach whilst holding onto the importance of the body as a crucial aspect of health that is sometimes lost in the psychological approaches. Although the model may not meet the criteria for use in academic research, it ‘legitimised the concept of talking to people as people’ (McLaren, 1998) when they were in receipt of medical care. For low-intensity psychological practitioners, the simplicity of this approach—it is often represented as a Venn diagram of three interlocking circles—makes it an appropriate method by which we can acknowledge the whole picture of a patient’s difficulty whilst providing a rationale for our focus on the psychosocial aspects of their experience. Disease and illness: Disease is an objective, measurable difference from a ‘biological norm’ (Boyd, 2000) whilst illness is the subjective experience of being unwell. In the IAPT team where I prasticed, it was our habit to link the concept of illness to the bio-psycho-social model. Acknowledging that changes in the body and in psychological and social health would combine to create the experience of ‘illness’. The five areas or five part model: A generic model derived from the principles of cognitive behavioural therapy (CBT), developed by Christine Padesky, that we use in low-intensity work to make sense of the problem that our patient wants to change. The model offers a way to capture the life/environment/situation of the patient and the aspects of their thoughts, emotions, physical experience, and behaviours that form part of the problem or difficulty that they want to change. It also has a role in identifying cycles of external triggers, physical symptoms, emotions, thoughts, and behaviour that can maintain the presenting problem or problems. The use of the model to map the symptoms and identify their interactions helps us to plan which strategies or intervention might be most effective. Health: The World Health Organisation Charter proposes that ‘Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’ (WHO Interim Commission, 1948), which acknowledges the multifaceted nature of health but indicates that none of us will live a completely healthy life and that many aspects of health will be affected by environmental and societal factors that an individual cannot control. An alternative definition is ‘the ability to adapt and self-manage’ (Huber et al., 2011) which more closely correlates with the concept of wellbeing and fits very neatly with the ethos of low-intensity psychological interventions. Integration: Refers to coordinated healthcare services that provide care for physical and mental health in a seamless way, without unnecessary delays caused by administrative or geographic barriers to access. ‘Care that is planned with people who work together to understand the service user and their carer(s), puts them in control and coordinates and delivers services to achieve the best outcomes’ (NHS, n.d.). Long-term health conditions (LTC): Diseases and health conditions that cannot currently be cured but have to be managed, often for the lifetime of the patient. Medically unexplained symptoms: Persistent physical symptoms which cannot be explained by an identified disease process, injury, or other causes. Sometimes described as ‘illness without disease’ or in terms of ‘somatisation’ and ‘psychosomatic’. Quality of life: Quality of life is defined by the WHO as “individuals’ perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns.” When we use the term ‘quality of life,’ in my experience, we usually mean something like ‘how good someone feels that their life is’. A good quality of life is usually assumed to be more attainable with good physical health. If the definition goes beyond economic prosperity, consumption, and acquisition to incorporate access to valued activity, a sense of meaning and

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purpose, and social connection, then a psychological intervention, as described in this chapter, can clearly support someone to improve their quality of life, even in the presence of physical health problems and limited mobility. Wellbeing: A holistic and individual concept ‘wellbeing’ encompasses all aspects of life and boils down to an individual’s sense that they are ‘well’ as opposed to ‘unwell’. The USA’s Centers for Disease Control and Prevention proposes that measures of wellbeing are measures of how much ‘people perceive that their lives are going well’ (2018). The presence or absence of a disease or illness does not determine a person’s perception of wellbeing, nor does age, financial resources, or social status. All of those elements amongst others will be part of a whole picture that encompasses environmental, spiritual, social, psychological, and physical aspects of experience.

Mental health in physical healthcare In England, the King’s Fund, a charity with a focus on improving healthcare, estimates that more than 16 million people (nearly one-third of the population) will live with one or more long-term health condition (LTC) and current estimates are that between one-third to one-half of the UK population live with chronic pain, with up to 15% of that number disabled by the pain (https://bmjopen.bmj.com/content/6/6/e010364). The statistics about the overlap between physical and mental health is striking. The presence of one long-term condition increases the risk of depression and anxiety significantly, with at least 30% of the people who live with an LTC expected to also have symptoms of a mental health condition. For comparison, the mental health charity MIND estimates that around 25% of the general population will have a mental health problem every year. When the LTC falls under the MUS descriptor, the risk of depression and anxiety goes up to about 50%. These figures are based on survey data from 2014 and are referenced in the IAPT LTC full implementation guidance. There was already an upward trend in these figures in 2014, and it would be surprising if those numbers hadn’t increased in the wake of the physical, social, and psychological stress of the COVID-19 pandemic.

Introducing Sarah Sarah qualified as a registered nurse in 1989, she has spent the majority of her nursing career working in the community, and her expertise is in caring for people with long-term health conditions. Sarah began her psychological wellbeing practitioner (low-intensity psychological practitioner) training in 2013, and since qualifying as a PWP, Sarah helped to set up an IAPT wave 2 service and was part of the team that develops and delivers the IAPT LTC top-up training for PWPs and CBT t­ herapists at the

University of Sheffield, alongside her role as Lead Community Matron in the city of Sheffield. Sarah was kind enough to speak to me about her experience as a senior physical healthcare practitioner who trained in low-intensity psychological interventions and who continues to utilise her skills as a psychological practitioner in her physical healthcare role. Selected quotes from our conversation are scattered throughout this chapter to add an additional perspective to the topic.

The IAPT long-term conditions expansion LTC work was always on the IAPT agenda; the prevalence of depression and anxiety in the population of people with LTCs made this inevitable. The IAPT programme expanded into ‘LTC work’ as we spoke about it colloquially, in 2012/2013 with a national pathfinder in which a handful of IAPT services developed pieces of work that aimed to provide psychological care that was integrated with physical healthcare pathways. You can read more about learning from the pathfinder sites in McCrae et al. (2015) and Kellet et al. (2016) (the latter is a paper on the pathfinder work that I contributed to!). These articles both highlight that a high volume of the work that took place in the IAPT LTC pathfinder year was delivered by low-intensity practitioners. There was also a recognition that additional practitioner training was essential if this work was to be done safely and well. Working in the overlap between physical and mental health is more complicated than work with a single mental health or ‘wellbeing’ focus.

NHS planning In 2014, an NHS planning document called The Five Year Forward View outlined the need for increased integration between health and social care services and strengthening of mental health provision; this was reiterated in the Five Year Forward View for Mental Health in 2016 and in the NHS long-term plan published in 2019; these planning documents were backed up by promises of significant government funding. For IAPT, this meant money became available to expand

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the workforce, to add additional teams with staff who completed postqualification training in work with people who have long-term conditions and persistent physical symptoms. The traditional divide between primary care, community services, and hospitals—largely unaltered since the birth of the NHS—is increasingly a barrier to the personalised and coordinated health services patients need. Just as GPs and hospitals tend to be rigidly demarcated, so too are social care and mental health services even though people increasingly need all three… the NHS will increasingly need to dissolve these traditional boundaries. Long-term conditions are now a central task of the NHS; caring for these needs requires a partnership with patients over the long-term rather than providing single,

unconnected ‘episodes’ of care (The NHS Five Year Forward View, 2014, p.16). Sarah: Some people come on the IAPT LTC top-up course expecting to be told something new. They think there’s going to be a whole new skill set … but, no, there isn’t. We still get comments saying “I’ve not learned anything … I thought there was going to be more on how to treat somebody with asthma.” That misses the point. It’s about creatively using core PWP skills in the context of an LTC.

What’s a low-intensity practitioner to do? The available data highlight the extent of the need for effective service provision for people with overlapping physical and mental health care needs. Just as, in the days before IAPT, there was a vast and unmet need for effective psychological treatment of common mental health disorders that provided the impetus for the IAPT programme (see Chapter 1 of this book for more detail). There was also good evidence that depression and anxiety could significantly impair a patient’s self-management of their physical health condition, leading to loss of compliance with treatment protocols, worse clinical outcomes for the patient, and a more utilisation of healthcare services (Ludman et al. 2013).

Specialisation After a year or two of ‘core’, or general, low-intensity work, many practitioners start to look for opportunities to develop their clinical practice. Some of us become particularly passionate about how low-intensity psychological interventions can be helpful for a specific group of patients. Developing into an area of specialisation often means learning and imagining ways to deliver the low-intensity strategies and interventions with fidelity and flexibility. We have to figure out how to make changes to increase the relevance and accessibility of the theory and strategies for different groups of people, without drifting away from the evidence-based models and principles. I have worked with psychological wellbeing practitioners who light up when they talk about the efficacy of adapted lowintensity interventions for parents in the perinatal period, or in the context of substance misuse and addiction services, or when adapted for people with learning difficulties, or for faith communities. For me, the area of work that makes my heart race is integrating low-intensity interventions in physical healthcare settings. In part, this is because of my own experience of living with a chronic health condition.

A personal perspective I was diagnosed with myalgic encephalomyelitis (ME, sometimes known as Chronic Fatigue Syndrome or ME/CFS) at the age of 13 and had life-changing benefit from a low-intensity CBT-based psychoeducation course when I was 24. When I talk and write about this subject, I offer the perspective of both an experienced practitioner and a patient. CBT-based treatment didn’t cure my health or restore my quality of life to that of a healthy person. At the time of writing, nearly 30 years after diagnosis, I am still restricted and have to actively manage the symptoms of the physical health condition every day. Although not a cure, the CBT-based low-intensity programme that I attended as a patient in 2007 equipped me with tools that helped me to cope more effectively with the multitude of impacts that the physical health condition had on my wellbeing. It gave me the information that I needed to find and

maintain joy, purpose, and achievement which would otherwise have been scarce and elusive. When the IAPT programme expanded into long-term conditions work, I had largely (acceptance is rarely a completed process in these circumstances) come to terms with the social and psychological impact of my health condition and took a geeky interest in exploring how we could retain fidelity to the core principles and evidence base for low-intensity CBT-based interventions, whilst changing our ‘business as usual’ to be useful for people with the specific challenges that arise because of long-term physical ill-health. In 2016, I declined the opportunity to complete the IAPT High Intensity Interventions training, and become a CBT therapist, to take up a role as a Senior Psychological Wellbeing Practitioner (PWP) and later Lead PWP in a Wave Two LTC development. To this day, I believe that was the right choice to make.

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Part 2: Identifying themes in this area of work An intersectional lens LTC work takes us into areas where an intersectional lens becomes very important ● ● ● ● ● ●

Socio-economic status and poverty Age Disability Race and ethnic origin Cultural identity including affiliation with a spiritual or religious identity Gender and sexual identity

All affect how a physical health condition will be experienced and what accessing care and treatment will be like. Some of these areas of identity will also affect the prevalence, severity, and impact of long-term physical health conditions. This is in part because there are structural, societal level inequities in how systems and services are designed and delivered. This is at true in the NHS as in any other public institution in England. An (often rational and proportional) fear of discrimination will affect how someone uses healthcare services; James speaks to this in more detail in Chapter 6. Those structural inequities will affect how easy it is for patients to engage and benefit from the services that are available. The other factor is the effect of a patient’s culture and family beliefs about health and how health interacts with things like spirituality and status. In the UK, we have got a racially and culturally diverse population as well as ‘a population where more people are living longer with complex and multiple long-term health problems’ (Beck, 2022, personal communication). There are also huge disparities in the distribution of wealth with resultant significant socioeconomic inequalities. All of these factors affect the LTC landscape. The risk of being diagnosed with an LTC goes up significantly once you reach 60 years old, not to put too fine a point on it, being poor increases the risk of earlier LTC onset, and you’re likely to have more severe symptoms once you have a condition. Natasha Seaton et al. (2022) reviewed the outcomes from an IAPT LTC service and found that socioeconomic deprivation was associated with poorer outcomes in an IAPT service and recommended that specific interventions are delivered, tailored to account for this factor. These numbers are compounded by the statistics that say that certain racial groups are more likely to live in poverty, and there is good evidence that a combination of factors mean that people from Black and other minoritised racial and ethnic groups in the UK have less satisfactory outcomes from healthcare services than their white British counterparts.

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Unpicking the causes of ethnic inequalities in health is difficult. Available evidence suggests a complex interplay of deprivation, environmental, physiological, health-related behaviours, and the ‘healthy migrant effect’.2 Ethnic minority groups are disproportionately affected by socioeconomic deprivation, a key determinant of health status in all communities, but it is not clear if the relationship applies equally across all ethnic groups.

Amongst ethnic minority groups structural racism can reinforce inequalities, for example, in housing, employment, and the criminal justice system, which in turn can have a negative impact on health. Evidence shows that racism and discrimination can also have a negative impact on the physical and mental health of people from ethnic minority groups. (Raleigh and Holmes, 2021) ‘The health of people from minority groups in England’. Kings Fund. ●

Patient A It can be helpful to use a case example to illustrate how some of these factors could interact to make the provision of physical and psychological care more complicated. ‘Patient A’ is not a real person but a representation of the experiences that were described by several dozen people during my time as a low-intensity psychological practitioner in an IAPT team. Patient A attended for a low-intensity assessment and scored in the severe range on both the PHQ-9 (a measure of depression) and GAD-7 (a measure of generalised anxiety). They were living in social housing after several years of uncertainty and waiting within the immigration and social housing systems. Their house had black mould on the walls; one of their children has asthma and this person was constantly worried that the mould would affect the child’s health. Despite frequent efforts to contact the social housing charity to have the mould removed, no one had come to treat the mould. The patient felt frightened to leave the house because they had witnessed several violent crimes, including a shooting, on the street outside their new house.

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This patient arrived in the UK as a refugee from war 5 years before we met and had only just been granted the right to remain in the UK, and given a house. They don’t speak English but were attending a language class. They were struggling to remember anything from the lessons, and this upset them. They worried that they would be blamed for not learning English, even though they worked hard to acquire the language. Most of their family were in the country of origin and the patient knew that their close family were in danger daily and felt guilt that they and their children were safe whilst others were not. The patient reported broken sleep, nightmares, and spent several hours sitting and dwelling on the past every day. Patient A is not literate in any language, so the materials that I prepared in their own language ahead of the session were not used. They brought a letter from the Job Centre into the appointment and asked me and the interpreter to read it for them. The letter turned out to be for an appointment at the Job Centre that the patient had missed which meant that their benefits payments could be reduced or stopped in penalty. The GP had referred the patent to physiotherapy because of their severe neck and shoulder pain, and to a food bank. The patient had got friends in their local faith community who visit them at home and took them on occasional outings to the park and countryside. The patient had not told their friends how they felt because, they explained, people already thought less of them for not working, and if they told people that they were depressed then no one would speak to them. As the assessment progressed, the interpreter explained that in their language that there is no word for ‘worry’ and the patient repeatedly spoke about their physical pain. On the way to the UK, they saw a doctor in Pakistan who did a scan and prescribed diazepam, which helped with the pain. The GP in the UK won’t prescribe this medication but did refer them to a physiotherapist. The patient says that physiotherapy doesn’t help and asked me for pain medication and an MRI scan so that the English doctors would prescribe the correct medication. They also asked me to get someone to remove the mould from their house and write a letter to the Job Centre. Let’s think about Patient A. Their list of problems looks something like this: ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

Housing Query about children’s wellbeing Probable encounters with microaggressions and racism Language barriers/pressure and isolation Possible historical trauma and current ongoing threat to loved ones Food insecurity Benefits Lack of employment/meaningful activity and routine Worry and anxiety Rumination and depression Insomnia Long-term pain Moving from a different medical system into the UK system Illiteracy Lack of regular activity or movement

We know that none of these exist in isolation, they all interlock; they affect and maintain each other. Finding a way into that picture is a little bit like playing Jenga; you have to gently tap each brick until you find one that will move. It is in this kind of picture that integrated, community-based services really make a difference. I think about how this kind of care can be provided later in the chapter.

Reflect A low-intensity psychological practitioner in the NHS has to attempt to provide an assessment for anybody who has an assessment appointment booked with them. There are rarely any screening systems in place between the public and the low-intensity practitioner (and it’s debatable if there should be). As a psychological practitioner meeting this patient, please think about how you would approach the assessment: ● ● ● ● ●

What would you prioritise? How would you adapt your ‘business as usual’ to make your service accessible to the patient? How might you feel? Would you be supported and equipped to provide a good assessment and sensible treatment or care plan? Can you see a role for low-intensity psychological interventions in this picture?

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● ● ●

Would that treatment be the priority? What would be the role of supervision? Working in your local health and social care context, how might encounters with a high volume of people in similar situations affect you in the long-term? Would there be an effect on your worldview?

What should we hold in mind? Considerations around the intersecting identities held by the people who we are trying to help should always be on our mind as practitioners. There is a policy-level and service design-level of responsibility as well; to consider how services are designed and what standards they are measured against, and to ensure that no group of patients is excluded from care. In IAPT, we not only have staff reporting that they experience direct and indirect race-based discrimination as they go about their work, but practitioners who report being unable to offer longer sessions or more sessions when an interpreter is employed. There is a national shortage of therapy materials that are translated into the languages most commonly spoken in our communities. For example, in my home city, around 17% of the school children don’t speak English as a first language, but we were still unable to source reliable and good quality translated self-help material when we were providing psychological care for their parents. James has written a chapter in this book that further explores the barriers to providing effective and responsive care for people who live amongst numerous societal barriers because of who they are.

Our experiences of health and wellbeing are fundamentally influenced by the cultural contexts from which we make meaning. These frameworks inform the beliefs and actions of … health care practitioners as much as the people they serve. For this reason, policy-makers must seek not only to understand the values they attribute to others but also to critically examine their own cultures—their perceptions, daily practices, and processes of decision-making—and their effects on people who may or may not share the same values and priorities (Napier et al., 2017.)

Levels of response So, what to do? I can’t speak to the legislation, service, and policy level considerations in this book, but Amy Edwards and colleagues (Edwards et al., 2022) make an uncompromising and excellent comment about this in the BABCP members magazine ‘CBT Today’: ‘We call for those placed in positions of power or privilege to take committed actions, which are more than tick box exercises. This must be a committed step and sustained change requiring input from all levels, inclusive of but not limited to supervisors, management, commissioners, educators, training institutions, the IAPT National Team, NHS England and political leaders’. Addressing considerations on that level is another piece of work that several groups and organisations are taking up, including the NHS Health and Race Observatory, the Race Equality Foundation, the King’s Fund, publications from all of which have informed this chapter. I can speak a little bit to the practitioner-patient interaction level of these considerations. ‘Responding effectively to the needs of diverse patients involves aligning caregiving practices with how care is understood and experienced by those receiving it’ said David Napier in the 2017 World Health Organization policy document ‘Culture Matters: Using a cultural contexts of health approach to enhance policy-making’. This offers a challenge to a behemoth like IAPT where—although service is paid to the idea of collaborative and patient cantered care—standards and outcomes are measured by benchmarks that reflect a very specific worldview and that ultimately assumes ‘one size fits all’ when it comes to understanding and managing psychological difficulties. The migrant health guide from the Office for Health Improvement and Disparities recommends: 1. Describing how the NHS/your service works. 2. Discuss how this is different from what the patient is used to or what they expect. From there, our core skills of negotiating a meaningful goal for treatment collaboratively describing the problem that is preventing the patient from achieving that goal and planning a course of treatment using the low-intensity treatment strategies and interventions should kick in.

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Acute illness compared to chronic illness When you think about the experience of illness that you have had, and what you have observed amongst the people around you, it is easy to see where our assumptions about healthcare come from. You don’t know anyone who has lived a ­completely healthy life with no physical problems. Everyone will have had a viral or bacterial infection (usually multiple), an injury like a sprain or fracture or cut, a stomach upset… no one escapes physical ill health. Of course, the majority of people, at least up until older adulthood, will experience only acute health problems; that is health problems that are easy to understand, that resolve, and that do not have a lasting effect on life. Care and treatment for acute health problems are very different to the care and treatment of the types of chronic illness that we are focused on in this chapter. It can be helpful to acknowledge the many differences in the experience of acute, or short-term, illness and chronic, or long-term, illness. In the table below, I have listed some of the dimensions of life and care that are involved in living with a long-term health condition, and described what the difference between an acute and chronic illness might look like (Table 5.1).

Reflect How many of our cultures place doctors and other physical health professionals on a pedestal, imbuing them with power and authority, and with unreasonable faith in their curative ability? What is the effect of this on patients whose physical health needs fall outside of the scope of diagnosis and cure?

Knowledge is power Sarah: And one of the assignments that I wrote then was on “knowledge is power.” There’s a range of books on medical knowledge, medical power, and how doctors hold so much power in society, within healthcare organisations, and how the amount of knowledge that they hold translates into power. And I think you could say the same about senior nurses and specialist nurses. But it’s kind of like disempowering the healthcare professional in order to empower the patient.

Liz: Yeah, because we specifically teach on the core PWP training that our job is to give power to the patients. We want to transfer our knowledge to the patient and build up their efficacy, and that’s, I think, to me, that’s the heart of low-intensity work; and it’s the opposite of that, isn’t it, medical care sometimes? Sarah: Yes, and that’s how they’re educated. That’s how they’re socialised. It comes with their medical training. Although we’re seeing that power balance starting to shift somewhat as current healthcare policies are putting more emphasis on p ­ atient ­empowerment (the NHS Long Term Plan, for instance).

Dual-trained practitioners You might remember from the first chapter of this book that one of the precursors of low-intensity psychological practitioners was mental health nurses and social workers who undertook postqualification training in cognitive behavioural therapy (CBT). The idea that counselling and CBT training could complement the work of those with a ‘core profession’ in physical healthcare is not new; there are initiatives, particularly in nursing training but also in other physical healthcare training programmes, that integrate some mental health awareness and training in CBT-based interventions within the programme.

For example, in an assessment of a patient with back pain using physiotherapy questioning, it might become evident after a few minutes that the patient’s depression is a barrier to them engaging in appropriate management. If this is the case, assessment can introduce the 5 Areas model and lead to the patient recognizing for the first time the role of their mental health in the problem. Commonly they ‘had a feeling’ their mental health was a factor but nobody had discussed this with them. This approach has led to treatment being combined and the most common example would be using behavioural activation (BA) instead of a rigid physiotherapy exercise programme. (Firth et al., 2016, unpublished.)

TABLE 5.1  Acute vs chronic conditions. Acute health condition

Chronic health condition

Recognition

Usually, a quick onset and easy to diagnose. The changes in the body (injury, infection, disease) are recognised with no or minimal investigation. Medical professionals are familiar with effective treatment protocols.

May have either a sudden or a slow onset and may require multiple tests and prolonged investigation. This might lead to an uncertain diagnosis ‘all of the tests are normal’, or recognition of a long-term health condition with a known aetiology.

You (the patient)

Seek help appropriately when you become aware of a change in health Don’t go to the doctor if there are effective over the counter remedies available Attend appointments and communicate effectively with medical staff Submit to tests and provide samples as needed Follow the advice given and take medication as prescribed Follow the best available advice on diet, exercise, and substance use to protect your health and prevent illness.

Monitor your symptoms and respond to changes using the information and advice that you have gathered Support your health as well as you can by eating healthy food and moving when you can within your new limitations Be proactive in learning about your condition and what helps people to live well with it (but don’t spend hours every day searching the internet for a miracle cure!) Learn how to accept the changes that you live with without giving up hope that new information and understanding could emerge in the future. This might involve going through a grieving process for your ‘old self’ and the life that you expected to live Maintain relationships with healthcare practitioners, friends, family, carers, and colleagues Learn new skills like pacing to manage fatigue, breathlessness, or pain Problem-solve how you will complete necessary activities like childcare, paying the bills, maintaining a hygienic and comfortable home, within the new abilities of your body Advocate for your own access to care Wherever possible and if you are able, challenge stigma and the bad science that often supports discrimination Don’t follow advice just because it is given by a doctor or healthcare professional. You might know the condition better than they do and you should discuss the safety of the advice that you are given.

Doctors (usually your GP or a hospital consultant)

Investigate, diagnose, advice, and prescribe. They attend to the ‘bio’ part of the bio-psycho-social model.

The doctor’s role may diminish over time once initial investigations have been completed. They should regularly review repeat prescriptions of medications and stay up to date with the latest research evidence and follow guidelines for the care and management of your condition.

Other physical health professionals (general and specialist nurses, physiotherapists, occupational therapists, dieticians, etc.)

Often not involved but might refer you to a doctor for further investigations and diagnosis if they notice symptoms that need investigation or treatment. Might be part of a rehabilitation programme after an injury.

Support to manage a condition in the longer term with nutritional advice, exercises to protect muscle strength, balance and joint flexibility, adaptations and equipment at home and work to make activity more comfortable. This group may answer helplines and be able to signpost you to peer support groups and other relevant organisations They should stay up to date with the latest research evidence and follow guidelines for the care and management of your condition.

Psychological professionals

Usually no role, unless you are already seeing a therapist about something else.

These might be the professionals who have got the time and skills to listen properly and understand what living with the condition is like for you, and how you feel about it They might be able to help you to come to terms with the loss and changes in your life. You might be able to access information and advice on how to manage symptoms of depression and anxiety in the context of your health condition. They might help you to understand the many factors that affect how you feel and what you do, and support you to make some helpful changes.

Friends, family, and colleagues

Everyone will have experienced acute health problems at least once in their life. They are likely to be able to relate to what you are experiencing. Impact on relationships and work is usually small.

People might become impatient and wonder why you aren’t getting back to your previous level of activity You might feel like you can’t explain what the experience of your condition feels like Many people describe that they feel guilty or ashamed by the changes that have occurred in how they get on with other people, especially if they can’t live up to responsibilities and expectations like they used to It might take more work to maintain relationships On the other hand, sharing your experience with the people closest to you and negotiating what you can and can’t do, and what help you can accept, can strengthen relationships. This can become a very hopeful and nourishing part of your life.

Peer support groups/ condition-specific support groups.

Usually not needed.

There are often charities and patient-led organisations that provide information, advocacy, lobbying, and support. Some of these might provide medical helplines and a counselling service.

Complementary and alternative therapists, spiritual and faithbased support

Many people use folk and herbal remedies, supplements, and rest. Faith communities might rally to provide food, company, and practical help if someone has limited mobility for a short time.

Many people use folk and herbal remedies, supplements, and rest. Communities of patients might form on social media to share ideas of remedies and routines that provide relief or better management of symptoms Over years, it is likely that a range of supplements, restrictive diets, and spiritual healing practices will be attempted when there is no clear medical guidance or effective relief from symptoms in from healthcare services Some religious officiants will visit community members at home so that they can participate in the rituals of the faith whilst they are housebound.

Outcome

Full recovery and return to previous activity.

As natural healing and/or fluctuations in the condition take place, or medical science advances, there might be some improvement in symptoms, or an effective treatment might be developed There might be a persistent, unwanted, possibly lifelong effect on every area of your life.

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Bridging the gap Locally, the Health Education authority initiated a programme in response to the Five Year Forward View (Care Quality Commission et al., 2015); this programme had the goal of ‘bridging the gap’ between physical and mental healthcare and involved a number of physical healthcare professionals—physiotherapists, occupational therapists, and general Nurses—undertaking the PWP 1-year training programme and working within an IAPT team for part of the week during the training year. We were fortunate to work alongside these practitioners and I provided some ongoing supervision for a few of the trainees as they completed their work in IAPT and implemented their training as psychological practitioners in their physical healthcare roles. The physiotherapists who trained in this project produced a report in collaboration with Moira Leahy, a consultant clinical psychologist in the host NHS Trust. The authors generously shared this unpublished report (Firth et al., 2016) with me in preparation for this chapter. Within this reflective report, it is easy to see that the practitioners were often motivated to train as low-intensity practitioners by an awareness of a gap in their professional skill set. One physiotherapist describes being in a situation where they had to incorporate management of mental health conditions in a physical health setting and felt ‘I was completely out of my depth’, another described that ‘I was seeing a large number of complex patients that were stressed, anxious and/or depressed and I had no idea how to help them!’, and a third states ‘I felt I had a missing link in my skills’. In an interview for Frontline, the members magazine for the Chartered Society of Physiotherapy, Nicola Willcocks highlights the benefits that training provided: improved communication with patients and the opportunity to disseminate learning from the PWP training within her physiotherapy team (Frontline, 2015).

The elephant in the room Patients with an identified disease are likely to have a different response to the suggestion that they might benefit from a psychological intervention than somebody with a “functional” or medically unexplained symptoms label attached to the physical symptoms that they are experiencing. Patients with a physical problem often want a physical solution—if the symptoms went away, the source of distress and difficulty would be gone. In fact, it is sensible to complete all appropriate medical investigations before starting a psychological intervention for this very reason. If there is a cure for the physical health condition—great, do that! You might eliminate the need for psychological intervention by removing the source of distress. Experiencing LTCs when the doctors tell you that all test results are ‘normal’ is not just frustrating but that is a situation rife with uncertainty. What if they have missed something, what if there is a cure somewhere but it is not being offered because of cost? If the doctor can’t do anything, who is going to help you? In that context, a referral or recommendation for psychological care can feel like a brush-off, or that someone is suggesting that your suffering is ‘all in your head’ or a result of flaws in your personality.

Root or rhizome? Academics in the fields of psychology and psychiatry have attempted to redefine the terms being used, as in Deary’s paper ‘Explaining the unexplained? Overcoming the distortions of a dualist understanding of medically unexplained illness’ (Deary, 2005). Deary proposes that instead of our current binary understanding of illness and disease—that illness either originates in the body (can be understood by medical science and is “real”) or the mind (and is therefore less real because the root causes cannot be identified by current medical diagnostic tests)—a network of processes across the biological, psychological, and social aspects of health could equally contribute to the onset and maintenance of illness. Instead of looking for the ‘root’ of the illness in the body or mind, he proposes the image of a lateral network of rhizomes. This is curiously similar to the definition of functional neurological disorders (FND) that Abbas and colleagues propose: ‘conditions characterised by persistent and troublesome physical symptoms that are accompanied by impairment or disability and that reflect the complex interaction of biological and psychosocial factors and the integration of bodily and brain functions and dysfunctions… neither purely somatic nor purely mental’ (Abbas et al., 2021). Where Abbas and colleagues are describing FND specifically that Deary’s rhizome model could equally be applied to health conditions with a recognised disease process.

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When the evidence doesn’t suit It is interesting that Deary specifically provided the example of ME/CFS in his article to illustrate the agility of the care system to adapt to new information because worldwide new information about the biomedical processes involved in this illness are being identified (see, Maksoud et  al., 2021; Zinn and Jason, 2021). However, this has not translated into alterations in the conceptualisation of the illness within care systems in England. In 2021, NICE released new guidelines for the treatment of ME/CFS amid a political storm. Researchers who have based treatment interventions on a psychosocial model of the illness were told that their clinical trials and research methodology were not of a good enough standard to enable NICE to support their suggested treatments. Rather than adapt to the evidence review and changed guidelines, as Deary predicted, researchers doubled down on their insistence that they had accurately conceptualised the illness and been correct in their treatment recommendations (Sharpe et al., 2022). For the first time, several Royal Societies issued statements saying that they would not support or implement NICE guidelines when they were published. Healthcare services have opted not to change their offer in response to the changed guidelines. On the other hand, patient groups greeted the new guidelines with relief. It felt as if someone was finally ­having a proper

look at what was going on with this health condition and doing something to protect patients from chancers who were exploiting the lack of bio-medical research into this health condition to promote their own pet theories. IAPT LTC has had a “Chronic Fatigue Syndrome” element for years. The current version of the IAPT manual (v.5 published online in 2021) contains a table in which “Chronic Fatigue Syndrome” is listed as a ‘primary mental health condition’ and there is an implication that treatment with CBT is expected to cure this condition. Attempts have been made to produce competency frameworks for Low Intensity Practitioners who work in this area (Rimes et al., 2014). This is at odds with the NICE guidelines for ME/CFS which state that ‘… cognitive behavioural therapy (CBT) has sometimes been assumed to be a cure for ME/CFS. However, it should only be offered to support people who live with ME/CFS to manage their symptoms, improve their functioning and reduce the distress associated with having a chronic illness’ (National Institute for Health and Care, 2021). This is quite a good description of the role of low-intensity psychological interventions in the area of LTC is trying to achieve in the context of any health condition. So, it’s going to be interesting to see how things shake out over the next few months and years.

Deary suggests that in this model, if new information were to come to light such as the identification of a physical mechanism that would explain ME/CFS, then the weighting of factors would shift to take this new information into account, and presumably, treatment would be aligned with the new understanding. Unfortunately, there is currently a gap of about 17 years between the conclusion of a research study and implementation into clinical practice, so this blithe assumption of the accommodation of new information still leaves patients in receipt of outdated treatments. Although papers like this might have originated in a genuine attempt to bridge the gaps in understanding between academic theorists and suffering patients, the attempt has been only partially successful, and emotions and scepticism can run high in patient groups that fall under the “MUS” umbrella.

A breakdown of trust There have been a number of attempts to hash out the role of psychological therapy in the area of illness-provoking physical symptoms that can’t be explained by the current knowledge and understanding in the medical sciences. The suggestion that profound, life limiting and sometimes crippling physical symptoms are “all in my head” quite understandably gets patients backs up. Or, I’ll rephrase that the psychological understanding of the mind–body interaction is quite complex and is often oversimplified in manualised packages of treatment that can be delivered by practitioners who don’t understand the nuances of the theory, and who don’t have enough time with the patient to deliver a treatment with true collaboration and shared understanding. Rushing in with the assumption that better anxiety management will make the patient active and well again can leave patients feeling afraid, angry, or ashamed, and can sometimes, as in Graded Exercise Therapy for “Chronic Fatigue Syndrome” do physical harm as well. This has led to a profound breakdown in trust and communication between some patient groups and the psychological professions. The words ‘CBT’ and ‘Bio-Psycho-Social model’ send some patient groups into a state of profound alarm, and this has grievously prevented some very unwell people from accessing what could be a supportive and helpful intervention. Geraghty and Scott (2020) rightly caution IAPT about treading where angels fear to in the MUS work. ‘Stay in your lane’ takes on whole new dimensions in this area of work; listening to patient groups about the barriers to accessing what can be offered by a psychological therapies service is essential. It is important to take the time to work with the patient to get a shared understanding of which parts of their problems are in the body and a consequence of a disease process, and which parts might be safely approached with a supportive psychological intervention. Both practitioner and patient have to be able to live with the uncertainty that sometimes we

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don’t know what’s going on, and treatment has to be guided by what feels safe for the patient and theoretically sound to the practitioner; ideally this partnership would be supported by sound medical advice.

The whole person There are some simple, you might even say obvious, ideas that underpin IAPT LTC work. These are that effective healthcare must be holistic, and effective healthcare systems must be integrated. In other words, we’ve got to recognise the physical, psychological, and social aspects of health and wellbeing, and provide seamless care that meets the individual patient’s needs in all of those areas. Traditional medical care for physical and psychological health has broken people into parts and artificially separated physical and psychological (or ‘mental’) health. The doctor (unless you are very lucky) will examine the body, order scans, and tests, compare the results against a predetermined normal, and present a conclusion to the patient. Physical treatment is often governed by algorithms and strict numerical guidelines and the conversation with a medical practitioner can feel directive and data-focused. Psychological care has historically neglected the body, delving into first subconscious thoughts in the psychoanalytic approach, and then behaviour, as is the case in behaviourism and most recently into the role of conscious automatic thoughts with cognitive theory. All of these are attempts to find the key to happiness and productivity by pinpointing where the patient has gone wrong, or what has gone wrong with the patient. Neither of these approaches makes room for social determinants of health and wellbeing, missing out on the impact of relationships and community support, education, financial prosperity and stability, experiences of discrimination and prejudice, and the comfort and security of a person’s home. When fear is real Sarah: You know the converse of that was … I remember going to see a patient who, according to the district nurses, was really anxious. Could I go and see the patient because of how anxious they were? It seemed they got very anxious when their wound dressing was taken off—because it was painful. I did a full as-

sessment with them and I said, “They’re not anxious. It really hurts and we need to manage the pain better.” So, having both sets of skills was really helpful. The poor patient was getting anxious because they were in absolute agony every time the nurses visited her and took the dressing off. It was really just a normal anxiety which wasn’t actually there the rest of the time.

The body plays a part It might be understandable that a practitioner will keep their focus on the aspects of a patients’ experience that they feel best equipped to effect. Still, the lack of awareness of the whole person displayed by both psychological and physical health practitioners can be startling sometimes. For example, in a training session for low-intensity practitioners, I described how we might assess an anxiety disorder using the five areas model. For training purposes, we usually proposed a trigger in the ‘situation’ box; in this case, I suggested that a person with Diabetes has noticed a new tingling sensation in their fingertips. The teachers then prompted the students to fill in the rest of the areas in the conceptualisation. ‘What might go through that person’s mind, what thoughts might they think?’ ‘Something’s gone wrong, my heart isn’t working properly, what if this is cancer, or MS on top of everything else? What if the sensation in my fingers has gone forever. I could end up in pain forever’. It was easy for the students to suggest examples of possible automatic thoughts that could occur after that event. The teachers went on ‘With that trigger and those thoughts, what emotion might the person experience?’ ‘Fear, frightened, panic, worry, overwhelmed. Hopeless’. So far, they had got the right idea. Then we asked, ‘So with that trigger and those thoughts and emotions, what physical changes might the person experience?’ We expected the trainees to provide the usual symptoms of activation of the sympathetic nervous system, what we call ‘the fight and flight response’: increased heart rate, faster breathing, feeling dizzy, sensations of hot or cold, shaking, and so on. One of the students typed into the chat of the online learning environment (this teaching session took place during a COVID-19 lockdown). ‘What if there are no physical changes?’ I was momentarily speechless; in my understanding, the body is intrinsically present and involved in every experience; this would be especially noticeable in an anxiety disorder where the activation of the sympathetic nervous system is the engine that powers the problem. It was a striking reminder that the people who are attracted to the psychological professions may not always value or know how to recognise and incorporate the body in their work.



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Culture clash As I worked in GP surgeries for the first 6 years of my low-intensity career, I was confronted by the other side of the great physical and mental health divide: those physical health professionals who did not acknowledge the impact of thoughts, emotions, and behaviour on physical health. These practitioners were also oblivious to the impact of physical health changes on the psychological and social health of their patients, and how this might affect long-term outcomes. In 2014, my IAPT team developed and started to deliver a ‘Living Well with Pain’ course. This was a simple package of CBT-based psychoeducation information which acknowledged the reality of living with long-term pain. Using the biopsychosocial model, the group was given an opportunity to talk about the potential psychological consequences of this physical reality. Our goal was to equip patients to manage symptoms of depression and anxiety using tools that had been adapted to their changed physical abilities. In addition to the traditional low-intensity information and strategies for depression and anxiety, we made relaxation and pacing skills a significant part of the programme, and incorporated a simple script and handout about acceptance of the pain that was based on principles from Acceptance and Commitment Therapy (ACT). That year I had one clinic every week in a GP practice building on the outskirts of the city. The “counselling room,” as it was known to the practice team, was one of three rooms along a short corridor, removed from the GP examination rooms. I was excited about our new course and wanted to generate referrals so that we could pilot it effectively. At the end of my morning clinic, I watched the building’s electronic appointment ledger to find out when the physiotherapist was available, and listened for the physiotherapist to close their door after their last patient had left. As soon as the patient had walked past my door, I ran out and introduced myself to the physiotherapist. ‘We’re developing a course for people who’ve got chronic pain, to help them to manage depression and anxiety. I wondered if some of your patient’s might find it helpful?’ The physiotherapist looked both annoyed and frightened. ‘I don’t know anything about mental health, we’ve got a team who do that’. ‘Oh, no. It’s just that if you’ve got patients who live with pain for a few months then the pain might affect their mood, and this course might help them to manage that side of things. I can give you a leaflet to hand out?’ ‘Like I said, there’s a team who know about that…’ She closed the door. Although I have been very fortunate to work with dozens of GPs, nurses, occupational therapists, and physiotherapists who recognise and attend to the whole person in their work, there are many medical and healthcare professionals who see the psychological experience of their patients as none of their business, to the detriment of the care that patients receive. Sarah highlighted this culture in our conversation: ‘It is the district nurses’ job to look after people’s wellbeing, yet they’re not contracted to specifically look after people’s mental health. We know that, if you look after people’s mental health, their physical health will improve, but it’s almost like we’re on a treadmill of simply focusing on their physical health. ‘…You’re the only person. There’s nobody else saying to the managers, ‘I think we should do this’ and so trying to get people to listen and understand was very hard. And then I just got things like ‘Oh, you know’ (like a bit of a running joke) ‘Sarah loves depression and anxiety, you know. That’s her favourite subject.’ And it was almost like there was something funny about it’.

Still in our lane As I have outlined in other chapters within this book, it is important to work within the limits of our approach and that is even more important in this area of work, where there are complexities that the standard low-intensity psychological interventions training doesn’t prepare us for. We aren’t going to cure a physical health problem with a brief, structured, goal-focused behaviour change method, but we can help patients to make sense of what they are experiencing and spot patterns that they might have fallen into that get in the way of living the life that they want. Our goal is to support the patient to manage their wellbeing and retain hope and purpose in the context of what can be truly grievous changes and losses, using very simple tools. Sometimes the best place to start one of these pieces of work is to simply acknowledge the huge effects that follow a loss of physical health. Many patients come to us after they have tried the medical model approach and it has failed to provide any help or relief. Sometimes we are the first healthcare professionals to say ‘what’s happening in your body is very difficult, but this isn’t just about your body, this has affected every part of your life’. Our simple models and formulations are an opportunity for a patient to pause, take stock, and receive some acknowledgement of what they are living with. From there, we can start to look for small changes that might equip patients with coping strategies and relieve some of the burden of distress.

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More complicated anxiety As my experience of working alongside physical healthcare providers expanded, so did my understanding of the limitations of psychological interventions and low-intensity interventions in particular. The needs that our patients presented with went far beyond straightforward depression and anxiety in the context of physical health problems; the boundaries of low-intensity work in this setting had to be defined quickly. Health anxiety is a real anxiety disorder; it is possible to become anxious about the body in a way that is disproportionate to what is really happening and for that anxiety to become overwhelming and controlling. However, sometimes we are too quick to offer anxiety as an explanation for what a patient is experiencing. For example, something like this account of a patient who presented to a ‘Health Anxiety’ psychoeducation course has happened more than once. ‘They were really anxious, convinced something was seriously wrong but nothing obvious stood out to the GP. The GP thought that anxiety would explain their symptoms and told them to come on the course whilst they were waiting for a couple more test results, everything that they described fit into the health anxiety model. After two sessions the results came back and there was a physical problem, the stuff that they had been anxious about was real and they had to go into treatment quite quickly…’.

Proportionate response The CBT-based interventions for anxiety that we use in low-intensity therapies are helpful and effective when the fear is out of proportion to the danger, or when the fear has a disproportionate, controlling, or debilitating effect on how someone behaves. In the ‘core’ IAPT work, it is usually quite a straightforward matter to identify an anxiety disorder and begin treatment using graded exposure therapy, exposure and response prevention, worry management, or low-intensity cognitive restructuring. It becomes more complicated when physical health is involved. How does a PWP know if someone’s back pain is the type that will have better outcomes with regular stretching and walking, or if further movement will cause damage and increase suffering? Our training doesn’t qualify us to make those judgements. Blanket messages that chronic pain is always harmless can be misleading for a small number of patients and we would only know which patients if a medical professional told us. Someone with chronic pain or chronic fatigue or breathlessness in COPD might become fearful of activity; experience might teach them that increased activity makes breathlessness, fatigue, or pain worse; their fear is rational and in proportion to the suffering caused by a ‘flare up’ of symptoms, but it also gets in the way of the things that a patient can do to improve their quality of life. How should a PWP find their way through that and support someone to understand and manage anxiety in a way that enables them to maintain valued activities in their life whilst living in real danger of debilitating symptoms? There aren’t easy answers to these questions. Work has to be delivered on a case-by-case basis with supervision from a practitioner who knows what they are doing and, ideally, with some access to medical advice. In practice, the work that a low-intensity practitioner can and will engage in is sometimes a matter of personal expertise and confidence, and the quality of their training and supervision, which is at odds with the idea of consistency in healthcare provision. Integration with physical healthcare pathways is fundamental to make this work safe; we should not operate in this area without strong working relationships, consultation, and information sharing with our physical health colleagues.

The circle of care Access to appropriate care, advice, and support can be transformative, but many patients with long-term health conditions are weary from new referrals made by healthcare practitioners who can’t provide any lasting relief from unwanted symptoms. Every new referral brings a rise in hope that a solution or cure might result. It is usually followed by a long waiting time and then, when an appointment is offered, patients have to navigate to a new location, find the correct waiting room (no small feat in maze-like hospitals that were originally designed in the Victorian era), and gamble that a competent and personable professional will conduct the appointment. They will usually have some kind of assessment during which the same information that they have provided to every other healthcare professional is repeated, there might be more tests, followed by another waiting time and then, often, no further contact with that person, and no real idea of what is happening with their care. A new medication might be proposed, a surgery might be offered, but the condition, and all of the difficulties that go with it, will usually remain. By the time someone has lived for a few years with a condition, they are likely to have been through several fruitless referrals, and also experienced periods of what can feel like neglect, where no healthcare practitioner is in touch or providing anything approximate to care.

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FIG. 5.1  The bio-psycho-social model with the circle of care. (Credit: Original image.)

A strength of the low-intensity model is that ‘signposting’ and networking have always been integral to the approach (Fig. 5.1). A requirement of the low-intensity training course that I attended in 2010 was to compile a database of local social and healthcare services, and visit as many of these services as possible, in order to support patients to access appropriate support for their needs. Familiarity with local health and social care services, including those provided by charities and other third sector organisations, is still a requirement of training courses today.

Integration Going back to the Five Year Forward View (2014), that document recognises that health services can’t provide for all the problems and needs that ill people will present with. Socio-economic status, education, family, religious, and geographic cultures will all contribute to lifestyles and behaviours that have consequences for health. So, it is essential for statutory, third-sector, and charity health and social care services to join forces. I have long thought about integrated care as the circle of care that we can provide around a patient who has needs in multiple dimensions of health and wellbeing. My use of these words should not be confused with the ‘Circle of Care’ model for Compassionate Human Factors in Healthcare, created by the Simulation and Interactive Learning Centre (SaIL) at Guy’s and St Thomas’ NHS Foundation Trust (GSTT). In this chapter, those words are simply the shorthand that I used in my own mind to describe an ideal version of service provision. A heart-breaking account of their care by a patient has stayed vivid in my mind. The patient described that living with chronic pain was a frightening and lonely experience. They had got an explanation for the onset of their pain; changes in their spine showed on scans, but there was no ‘cure’, that is, there was no medication dose that would eliminate the pain and let them get back to normal, and no corrective surgery was available. They described that they were emotionally overwhelmed by the difficulty of living in pain and had been to their GP a dozen times, trying to get the doctor to understand what it was like to live in so much pain, trying to get them to help. ‘I tell her [the GP] what it’s like, but every time I go all she does is give me a new tablet. I’m on seven tablets a

day now and none of them help me. Eventually she sent me here’. What the patient said wasn’t extraordinary; it was an often repeated story. Their level of despair did stand out as a reminder of how important it is to provide care that tends to all of the patient’s needs. Because the problem was identifiably in the back, in the body, the GP had not considered a referral to a talking therapies service until the patient had endured years of ‘coping’ alone. The patient had not been supported to adopt the skills needed for good self-management of chronic health conditions. They had not transitioned from a medical model approach to a bio-psycho-social approach to the management of their own health.

One of the greatest strengths of the low-intensity practitioner is the ability to complete an accurate assessment in a limited period of time. The core training for low-intensity practitioners in England teaches a 45-min assessment model. In 45 min, a practitioner can 1. establish rapport with a patient, 2. gather information on the most troublesome symptoms that the person is experiencing,

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3. collaboratively formulate these using the five areas model, 4. establish a shared and succinct definition of ‘the problem’ with the patient, 5. set goals for treatment, and 6. agree an action plan. Once all of the available and effective medical care has been provided, a low-intensity practitioner is equipped to work out what the priorities for support, treatment or intervention might be, and facilitate access to the most appropriate care providers. There are times, of course, when entry into psychological care of depression and anxiety are the most appropriate course of action and the low-intensity practitioner can swing into action as per their usual practice. Many patients with long-term health conditions and persistent physical symptoms will not intuit the need to self-manage their health condition, or conditions. The idea of self-management is at odds with the prevalent medical model. The internalised medical model can manifest in a belief and expectation that when we are ‘ill’, we will go to a doctor, the doctor will identify what is wrong, and they will make it better. This is the first unhelpful automatic belief and attitude that we ask our patients to examine. Medical science is not complete and perfect, and healthcare systems in many areas are a very long way from being adequate to the population’s needs. Doctors and other medical staff are essential to a functioning healthcare system but their role and use have limits.

Part 3: Implementation Liz: I’m guessing you’d agree that we’re not trying to cure somebody[‘s health condition]… Sarah: No, no. You’re trying to help somebody. The words that I use with patients are: “I’m trying to help you be as well as you possibly can within the limits of your illness.”

Getting started There is a simple exercise that I ask low-intensity practitioner trainees to undertake, originally inspired by chapters from Chris Williams’ Overcoming Depression self help guide (2001). You will need to understand the five areas model to complete this exercise (Fig. 5.2).

FIG. 5.2  The five areas model with a brief explanation of what the aspects in the model represent, based on Padesky (2020). (Credit: Original image.)

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Have a go: 1. Remember the last time that you felt physically unwell. You might have had a virus or bacterial infection, an injury, a hangover, or allergies. 2. Try to map how you felt in a five areas model; you can do this in any order and some prompts are here: ● Was there context or triggers for your illness in your life? ● When you were unwell, what physical symptoms did you experience? ● What kind of thoughts went through your head? (these might be memories, pictures or sentences, worries, or beliefs that go through your head). ● What emotions did you feel (these are usually described in one word)? ● What did you do or not do because of all of that? 3. You’ve probably got a picture that isn’t great—physical discomfort, certainly. It’s likely that your thoughts were a bit more gloomy or worried than normal; you might have felt less joy, curiosity, or contentment than usual. You might become less active when you’re unwell, or more irritable, or sulky, or you might push yourself—this isn’t going to beat you—with consequences back into what your body feels like. 4. For the short duration of this experience of feeling unwell, were there any effects on your situation? ● Did you have to miss a day of work and experience financial consequences? ● Did you miss a social event and feel that you were missing out? ● Did someone look after you and you now feel like you owe them a thanks or a reciprocal action? ● Did you try to make yourself feel better (self-medicate) with food, drugs, or alcohol, and now have to manage a strengthened reliance on substances? ● Did your ‘ill’ communication style affect any of your relationships? 5. An example of how this might look is provided in Fig. 5.3 below this box. At this point, you’re recognizing some of the widespread effects that even a ‘normal’ illness can produce. It’s likely that this isn’t catastrophic and when the illness or discomfort stops, your life will continue as normal. 6. Now imagine that the illness or discomfort doesn’t stop. It continues for several weeks; the doctor can’t tell you what to do to get better. You’re low in energy, maybe in pain. Your doctor might have given you some tasks to do, possibly to monitor your body and track symptoms. Maybe the doctor says that she can’t tell you when you’ll get better and has asked you not to keep going back to them about the same symptoms. 7. Now repeat the five areas for this new situation. What does it look like? Would you want that picture to describe what your life is like? 8. What might be the consequences for your mental health if this new picture continues for months or years? Do you think you would be more vulnerable to depression or anxiety? How would you manage it?

FIG. 5.3  A completed five areas for the experience of a bad cold. (Credit: Original image.)

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Assessment In Chapter 2, I tried to describe the importance of the assessment process in delivering a good low-intensity psychological intervention. You must define the problem that you are working on and your goal for treatment before you can make a sensible decision about what strategies or intervention to introduce. The assessment is even more important in LTC work where ignorance about the patient’s physical health and abilities can be dangerous. This is not business as usual for a practitioner; there are additional complexities, considerations, and responsibilities.

The power of a formulation Sarah gave an example of what a simple psychological formulation can do for a patient during our conversation. Sarah: Training as a PWP just made such a huge difference. So, in the conversations I’d have with a patient with a long-term health condition, I would rarely use the full PWP formulation: I’d just kind of weave it into things. So I might do a “five areas” formulation with somebody and that would be enough to find out what was going on, and then I would continue to do my “nursing” bit knowing the reason this patient is struggling. There’s one person that particularly comes to mind: I did a “five areas” formulation which enabled me to understand why this patient had become housebound. It was because of his anxiety about going out: he’d had a fall and didn’t want to fall again. So his way of preventing this was simply to not go out.

And then I thought, right, well, I’m going to do a graded exposure plan. And we’re going to get him to the garden gate. Then we’ll get him to the bus stop. Then we might get somebody to drive him to the shops, and then, eventually he’s going to go on the bus. So I talked to him about it, and when I went to see him the next week, he’d just been to the supermarket. That one is a standout example for me, because it wasn’t just about the outcome for the patient but also about me getting these skills to work in practice. Because this then had a huge impact on wider healthcare provision in my area. So I didn’t have to get the physio to see him at home; I didn’t have to order any of the pressure-relieving equipment that I thought I would need with this man being housebound and sitting in his chair all day; I didn’t have to get social services in to do his shopping; I didn’t have to get anybody to do his long-term condition reviews as home visits because he couldn’t get to the practice—he could go out again now. It was amazing.

WWIM Most low-intensity practitioners do not feel confident to explore the patients’ physical health within their typical assessment process. The WWIM model (Georgina Miles and Sarah Wilson, the University of Sheffield, unpublished) is a helpful structure for questions that can be incorporated into a structured low-intensity assessment process. The WWIM does not replace the usual low-intensity assessment structure but is intended to complement it. In addition to the usual assessment information gathering questions, when you are exploring a patient’s long-term health problems you can ask: ●

●

●

●

What is it? Does the patient know what their condition is called and anything about how the disease or illness is affecting their body? Who is involved in your care? This could include family carers as well as any peer support or medical and healthcare professionals. What Impact does it have on your life? Does the patient see this as a purely physical problem or is it having a wider effect on different parts of their experience? Is the condition making it more difficult to do anything? What do you do to Manage the condition? This could include prescribed or over the counter medications, changes in activity, self-medication with alcohol or recreational drugs; anything that the patient is doing to feel a bit more in control of what is happening with their health.

Measuring recovery Although there are encouraging outcomes on the classic IAPT minimum data set in the IAPT LTC services, the clinical outcome reports should be approached with some caution. In particular, the continued use of the PHQ-9 and GAD-7 to measure recovery and the success of a piece of work is tricky.

For example, the PHQ-9 contains items like ‘feeling tired or having little energy’, ‘having difficulty falling or staying asleep’, or ‘sleeping too much.” Both items are usually going to be scored ‘nearly every day’, or a numerical ‘3’—the highest score an item can receive—by patients with health problems that include symptoms of breathlessness, pain, or fatigue. You Continued

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can coach patients to disregard their physical health s­ ymptoms when they are filling in their questionnaires and answer only based on their mental health symptoms but, really, how realistic is that? A patient with chronic pain or diabetes that is interfering with their quality of sleep isn’t going to be able to say how much of their insomnia and tiredness is down to their physical health and how much it might be a consequence of worry or depression. The publicly available IAPT outcomes on NHS Digital show recovery rates for integrated work lagging a little bit behind the ‘core’ IAPT recovery rates. Given that patients who engaged with our LTC offer often reported significant relief from

distress and that they had felt ‘helped’ I wonder if a different measure of recovery would be more useful. Our local MSK/Pain Physiotherapy teams use a pain self-efficacy measure to good effect. The Patient Activation Measure (PAM) is particularly in line with the idea of integrated care and the ethos of the NHS Five Year Forward view (Care Quality Commission et al., 2015). The PAM measures ‘a person’s knowledge, skills, and confidence to manage their own health and wellbeing’ (NHS England, 2018). This was used in some of the work during the pathfinder year and the items on the PAM were a helpful guide that we could use in designing interventions as well as offering a way to measure our success in improving condition self-management.

Since you became ill, what has changed…? In the early stages of treatment, either working one-to-one with a patient or delivering a psychoeducation programme to a group, I would always try to acknowledge the bio-psycho-social model early in treatment. We would ask ‘since you became ill, what has changed in your life?’ Patients would provide a list of changes typically. ● ● ● ● ● ● ● ● ● ● ●

having to take medications every day; having to attend medical appointments and communicate with medical practitioners; the presence of symptoms—my body doesn’t feel healthy, I’m in pain, worn out, can’t concentrate, can’t sleep…; loss of spontaneity; loss of finances; loss or changes in sense of ‘self’. loss or changes in friendships; loss or changes in their role in their communities; loss of hope and an increase in gloomy, self-blaming thoughts; partial or total loss of activity, particularly work and social leisure activity; anger, irritability, grief, and sadness.

As we gathered the responses and reflected on them, eventually someone would say ‘It’s everything, this condition affects everything’. Doing this exercise in a group setting was particularly powerful because group members would hear each other describe similar experiences and changes and, often for the first time, realise that they were not alone in this experience. It was also a moment of realisation when the full extent of the changes in someone’s life was felt instead of avoided and the practitioner had to be able to gently acknowledge the emotional reaction to that realisation. The next step would be to arrange the changes that had been described into the biopsychosocial Venn diagram and explain that, although the patient was in the middle of those overlapping circles and experiencing changes in all of those areas simultaneously, there was no one source of care and help that could address that whole picture.

Who am I? When we are in this area of work, the likelihood is that we will work with people who have lost, or at risk of losing, their independence and are facing challenges to their sense of self. They may no longer be able to do the behaviours that reflect who they feel themselves to be so cannot show the ‘real me’ to the world. As low-intensity practitioners, we are not trained or equipped to explore self-identity with our patients, but we have to acknowledge that aspect of the presentation using our existing toolbox and interpersonal skills. The biopsychosocial model can be a way to provide acknowledgement and recognition of this aspect of someone’s experience, without diving off the deep end into an unstructured exploration of personality.

I would frequently point to the circle that represents the ‘bio’ or body part of the experience and explain ‘I’m useless here, I don’t know how the body works, and can’t prescribe medication or recommend physical therapy exercises’. Then I would point to the ‘psycho’ or thoughts, emotions and behaviours circle, and the ‘social’ aspects of health, where social might represent the roles, status, and relationships that the patient has with other people and within society. ‘In these two areas, I’ve got some ideas that might help you to understand and manage some of the changes that are happening’.

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Condition self-management and low-intensity interventions As a patient moves from the initial recognition that ‘something isn’t right’, through the process of medical investigation and diagnosis, and into life lived with long-term changes to health, there is a handover of knowledge and responsibility from medical and healthcare professionals to the patient. This transition culminates in the expectation that the patient will manage their own health in the long term, with little support from the healthcare system. Self-management of the condition is required of people with persistent physical symptoms, whether or not those symptoms are medically explained. Self-management is a substantial task and is often not explicitly explained to the patient who is expected to take up that responsibility. So, what is condition self-management and why is it so important?

‘the tasks … individuals must undertake to live with one or more chronic conditions … [including] … having the confidence to deal with medical management, role management and emotional management of their conditions’. (Taylor et al., 2014.)

I like this short quote from Taylor because it captures the range of the tasks that someone with a health condition is required to pick up. The irony of asking someone who is permanently unwell to do extra jobs isn’t lost on me, but many of these tasks are things that only the person who is experiencing the illness can do. At its best long-term condition, self-management enables patients to have an active role and some control in their own care instead of being a passive dependent on medical professionals. It starts with the person being able to recognise what their needs are, now that they are living around the presence of unwanted physical symptoms. This is at odds with the instinct to turn away from unwanted or difficult experiences that many of us will have. It is also different from an unhelpful and hopeless preoccupation with the things that feel difficult. Most low-intensity interventions ask the patient to start by being curious; with the five areas or ABC formulation, we support the patient to look at what is happening and ask questions about how one part of their experience affects the others. Self-management starts with this same task; asking what is happening in the body and what has an effect on how the body feels and performs. It also asks the person to acknowledge all of the areas of life that the condition has affected and adopt strategies that will help them to manage changes in the different areas of life. Taylor highlights three areas that the patient will need to attend to. Consider what might be involved in. ● ● ●

medical management role management emotional management

Of course, what is asked of a patient will be different from one person to another and will depend on what the physical reality of their condition is, what resources they have at their disposal, and many other factors.

Who’s who? This approach requires a significant shift in expectations. If a patient has only ever seen medical care of acute illness then it can be difficult to understand the different roles that healthcare practitioners play in management of chronic health conditions. Most people don’t intuit which healthcare professionals can help with which symptoms and questions, and most laypeople have never had cause to understand the difference between the types of doctor, the types of talking therapist, or between a physiotherapist and an occupational therapist, and so on. Memorably one patient who I provided

a course of treatment to called me ‘the depression nurse’ throughout our work together, despite my efforts to explain my job title and role. Many people go to their GP expecting a multispecialised medical practitioner who can also act as friend and mental health supporter with a bit of social work thrown in. The reality is that no one person can meet all of the needs and answer all of the questions that might arise, so people often have to learn how to navigate around complex systems and encounter a number of people whose role and responsibilities might not always be clear.

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Medical management Medical management might involve enduring uncomfortable tests. It might involve learning the limitations of the policies and guidelines that your doctors, nurses, and other allied health professionals work within which mean that sometimes tests and investigations won’t be offered, even if you ask for them. Medical management might involve complying with treatment suggestions like medications and doing this for a very long time. You might be advised to change how you fill your time and what you eat and drink. You might be asked to self-monitor certain symptoms and learn what symptoms should be managed by yourself, and which should be brought to the attention of a doctor. Effective management of the bio-medical aspects of a condition or illness can be transformative. For example, a patient with diabetes who implements the recommended lifestyle changes and self-monitoring might experience a new lease on life and live with minimal disruption from the health condition. However, changes like that are not straightforward to implement or maintain.

Role management Role management might mean figuring out the ‘new you’ when who you feel that you are inside yourself can no longer be expressed through the actions that you perform. You might become less financially affluent if your ability to work is reduced, or become a recipient of welfare payments if symptoms are so severe that you can’t work at all. You might go from being sporty and having active hobbies to being unable to complete those hobbies; some people become housebound and becoming sedentary can be a real risk. You might be less able to socialise, or have to socialise differently and be aware of how this might change people’s evaluation and judgements about you. You might go from a professional role into a more domestic-focused role. You might have to adjust to some, or a total, loss of independence. If you are single then the chances of attracting a partner might diminish. Depending on the prevalent attitudes towards physical illness and disability in your community and how visible your symptoms are, your social status might change. You become a ‘patient’ and if symptoms impair your movement and activity, you might become ‘disabled’. The condition might affect the dynamic in your roles as a spouse or partner, as a parent or child. You might go from being a caregiver or helper for children or elders in your family, to needing care from your children or parents. The behaviour of other people towards you might change when your health changes. Some people tell us about overprotective relatives who won’t let the person get off the settee to make their own drink, even though they are capable of doing so. Other people experience relationship loss as the change in health and ability puts strain on relationships. Some people find that their relationships and friendships deepen and become more meaningful; other people find themselves isolated. You might find that you have to think consciously about your roles and relationships in a way that you have not had to do before. You might have to think differently about how you communicate with different types of people and learn new skills to manage conversations where you are asking for help—or asking people to stop helping you. You might find that new roles and depth in your relationships become available to you that weren’t possible when you were healthy, or you might find yourself grieving for opportunities and an identity that is no longer accessible.

Emotional management Changes like these are not a small matter and it would be surprising if there were not some sort of emotional or psychological consequence; that is, changes in how you think about things, the prevalent emotions that you experience, and the ways that you behave. It is possible to live peacefully and with contentment, reward, and achievement alongside physical health conditions; the people who are doing that don’t tend to seek out our services.

Uncertain, unpredictable, and uncontrollable We had a slide in our early Long-Term Conditions group psychoeducation course that stated quite baldly that worry is more likely to occur when life feels more uncertain, unpredictable, and uncontrollable. Those three words could be a definition of living with a long-term condition, so anxiety and worry are common experiences amongst this patient group. Worry is tiring; it often disrupts sleep, causes muscle tension, can be linked to chronic headaches and can aggravate gastric symptoms like irritable bowel syndrome. Learning the low-intensity worry management strategies—identify worry, categorise it, and respond with either worry postponement or problem-solving—is a great example of long-term condition self-management and how our core skills can help.

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In the room One of the features of low-intensity work with people who live with long-term physical health conditions was what I came to describe, carefully, as ‘high levels of emotion in the room’. Low-intensity psychological interventions have the scope to acknowledge emotion, but it is never a focus of our work, and we don’t provide interventions or strategies that are designed to change emotions (although the changes that we support will often create an environment in which emotional health can thrive). Whether in a group setting or one to one appointments, anger, grief, and shame were often present in this work. We had to learn how to regulate ourselves in the presence of these emotions (try to maintain total calm whilst you’re standing alone in front of a room that contains half a dozen angry patients!) and support our groups and the individuals that we worked with to understand and navigate this aspect of the change in their health, and how to do that ‘live’ in the room, not expect it to be a home practice task. James’ chapters in this book on the interpersonal elements of low-intensity work are excellent supports for this area of clinical practice. In some respects, the core low-intensity interventions are the best thing that we can offer to support emotional selfmanagement. Adapted to the physical ability of our patients, worry management, problem-solving, support to improve the quality of sleep, support to learn and practise an assertive communication style, pacing informed by the principles of behavioural activation, and so on. These are all practical skills that a low-intensity practitioner can support a patient to learn, and all can have a role in helping the patient to feel empowered and come to terms with the situation that the health condition has forced them to live in.

More aspects of self-management As well as learning how to recognise and accomplish the tasks of condition self-management, a practitioner should also encourage behaviours that promote health. This might mean supporting the patient to explore how they can move safely, and how much it is safe to move. It might involve encouraging and supporting good nutrition to support the body to be as healthy as it can be and doing so without any judgement or blame or demands towards the patient. There is also a tentative role for encouraging behaviours that restore health. I say tentative just because a low-intensity practitioner should never suggest that they are going to cure a health condition and some symptoms require expert knowledge to manage, that a Low Intesnity Practitioner is not equipped with (Ogunbayo et al., 2017). What we can do is encourage active self-management of the bio-medical aspects of the illness and support any available rehabilitation that might have a restorative benefit for some patients.

Post exertional malaise (PEM) One of the striking differences between ‘core’ low-intensity practice and LTC. Low-intensity practice is the role of activity in treatment. In ‘core’ practice, where physical health is not presenting as a barrier to behaviour change and goal attainment, we are often in the position of encouraging and supporting an increase in activity. This makes sense when you understand that avoidance and decreased activity are characteristic of both depression and anxiety and will maintain both depression and anxiety. In LTC work, we could be in the opposite position; we sometimes had to encourage and support our patients to do less activity in order to manage their physical health more effectively. This can be counter-intuitive and one of the most important learning points for practitioners who are moving into this area of work. There is a common assumption that increased activity will always be safe and beneficial. This is most often the case—the human body is designed to move and tends to do better when given the opportunity to do so. We also know that moderate exercise (which should always be within the limits of what the individual body is capable of) can be

as effective for managing depression as an antidepressant medication. There is, however, a small group of patients whose bodies just don’t respond well to activity and these patients have what is called ‘postexertional malaise’ or ‘postexertional symptom exacerbation’, or sometimes ‘postexertional neuroimmune exhaustion’. I will refer to this symptom as PEM from now on. This symptom is the defining symptom of myalgic encephalomyelitis (ME/CFS) and is also seen in some patients with long COVID. NICE describes the symptom as ‘The worsening of symptoms that can follow minimal cognitive, physical, emotional or social activity, or activity that could previously be tolerated. Symptoms can typically worsen 12 to 48 hours after activity and last for days or even weeks, sometimes leading to a relapse’. You can find more information in the 2021 NICE ME/CFS guidelines (National Institute for Health and Care, 2021), from the Centres for Disease Control and Prevention in the USA and from various ME/CFS and Long COVID charities and special interest groups around the world. The websites from Physios for ME and Long COVID Physio are particularly worth a browse.

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Differentiating depression from a physical disability Why am I making such a big deal about PEM? Well, I have worked with several practitioners and students who have provided a low-intensity psychological intervention to a patient who has got ME/CFS or Long COVID who have misinterpreted the physical health condition as depression, simply on the grounds that the patient is less active than before they became ill. It is true that avoidance and reduced activity are characteristic of depression. In depression, avoidance and reduced activity are usually a consequence of a loss of motivation and interest in activities, and reduced pleasure and enjoyment from activity. Someone with depression might feel overwhelmed at the thought of engaging in an activity and experience some relief when they avoid the activity—we call this negative reinforcement. On the other hand, someone who lives with ME/CFS who does not also have depression (and having depression when you are ill is not inevitable) will usually be motivated to engage in activity; they (I should say ‘we’!) get the same pleasure and reward from the activity that they are able to do and when they are unable to engage in an activity because the severity of their physical symptoms prevents them, they are disappointed, not relieved. Our work with these patients often involves working with them, at least initially, to do less—to prevent PEM. Practitioners who are not aware of this are likely to mis-identify depression and take a typical approach to treatment— which is to support the patient to increase their activity using the Behavioural Activation approach. If you do this without assessment, awareness, and management of PEM and you’re very lucky, your patient will drop out of treatment because what you are doing doesn’t help them. If you’re unlucky you could harm the patient—causing a lasting increase in the severity of their physical health symptoms. We don’t have a validated tool for assessing PEM and most core low-intensity training courses and LTC top-up courses don’t include any information about this symptom so it’s worth bearing in mind; educate yourself from reputable sources and never ask a patient with an LTC to ‘push through’ symptoms to complete an activity.

Back to basics A patient who is new to the idea of self-management might need some support as they transition from the passive patient role in the medical model to the active and more responsible role they have in the experience of living with a long-term condition. The low-intensity practitioner might offer problem-solving or signposting, putting the patient in touch with the people who can provide the right information. If the patient already has the information that they need but hasn’t made the behaviour changes, then our skill with goal setting and providing a good rationale for change that builds motivation can come in handy. A COM-B assessment and time and strategies to overcome the barriers to behaviour change can be the right level of care in a complex picture.

Reflect I have given a very brief introduction to the idea of condition self-management and how a low-intensity practitioner might have a role in introducing this concept to a patient, and some of the skills and strategies that we can offer to support the development of condition self-management. Working with depression and anxiety in the context of a long-term physical health condition is a complex work. A quote widely attributed to Dr. Nick Gray became my motto in LTC work ‘in the face of complexity, go simple’. A practitioner with training and some time to think and reflect in supervision might be comfortable with the idea of condition self-management but how will it feel to the patient? ● ●

How does the idea of self-management fit with patient expectations? How does this fit with NHS/healthcare culture and the prevalent medical model?

Some patients live with a long-term condition for months or years without ever being told that they have got a chronic condition; they are not told what tasks and self-care routines they can adopt to effect what the experience of living with that condition will be like. A culture shift amongst healthcare professionals towards valuing and promoting and working collaboratively with patients to support this is needed at least as much as patients being willing to try to take up the tasks of being ill. If you are a healthcare practitioner, what would need to change in your own attitudes and practice to facilitate better patient self-management? If you are a patient: ● ●

How does condition self-management sound? Do you want to do it?

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● ●

What would need to change to help you to get on board with this idea? If you like the idea but don’t know where to start, who could help you to figure it out?

Supplementary interventions There have always been some ‘supplementary’ packets of information and strategy that are a good complement to the core low-intensity CBT-based interventions. Things like assertive communication skills, valued living questionnaires, and relaxation skills. These aren’t on the core training curriculum but are often powerful tools that help to remove barriers to behaviour change. These strategies are a helpful complement to core work but become much more essential for patient outcomes and building a collaborative relationship in LTC work.

Acceptance Many of the patients who came to our low-intensity psychoeducation courses, or attended our one-to-one appointments in the LTC team had been told, essentially, to ‘live with it’. When you consider what we have acknowledged about living with a health condition, I wonder how you would feel if you sought help for an illness and the medical, physical, or psychological practitioner who you wanted to help you said ‘there’s nothing I can do, you’ve got to live with it’? Especially if they said that but then didn’t tell you how to live with it. Talking to someone about ‘accepting’ a health condition is a conversation that needs to be navigated carefully. You mustn’t tell the patient off or make them feel that they have done something wrong by not intuiting acceptance and selfmanagement. Certainly don’t imply that anyone deserves to live with long-term health problems—nobody does. It’s normal to want to be healthy and to want the illness or condition to go away. Who wouldn’t want that? We never delivered Acceptance and Commitment Therapy (ACT) interventions in my team, but we borrowed some of their ideas for this conversation. In particular, ‘the box and the ball’ analogy made sense of why it might be worthwhile to try a low-intensity psychological intervention for problems related to your physical health. I can’t trace the provenance of this analogy, but it seems to also be used in work with grief as well as LTC (Fig. 5.4).

FIG. 5.4  A visual representation of the ‘box and ball’ analogy. (Credit: Original image.)

In this image, the box represents your life, and the ball represents the illness and all of the effects of the illness. Something like a health condition can take over and affect everything. As a patient, it is easy to become absorbed by the ball, you resent it, you want it to be gone so that you can have your life back the way that you want it to be. You’re grieved by everything that it has taken away from you and all of the suffering it is causing you and the people around you. If you’ve got any energy, you’re likely to spend a lot of it on feeling angry and resentful of the ball and doing everything that you can to get rid of the ball. Of course when the ball represents a currently incurable health condition, you could use all of your energy or ability to be active on ignoring or trying to get rid of the ball and the only effect you would have is to make the ball bigger—make symptoms worse and increase your feelings of failure and hopelessness.



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In the second box, the ball is smaller. This is often the goal that people have when they come to healthcare services ‘get this thing out of my life, I want my life back to normal’. People want help to affect the ball and make it shrink or go away. Unfortunately, in cases where the ball represents an LTC and its effects, that goal is out of the power of professionals as much as the patient. Everything that can be tried has been but the ball is still there. So, we need a different option. We call that option acceptance. Acceptance does not mean that you asked for or deserved the ball, it doesn’t mean being happy that the ball is there, and you don’t have to like the ball to accept it. Acceptance involves recognizing the reality ‘the ball is in my life’ without judgement—it isn’t good or bad, it’s just there. Once you stop trying to have a wrestling match with the ball, you can use all of the effort and energy that you put into that fight for something else, something that makes your life feel bigger around the ball so that the ball hasn’t taken over everything. Learning effective self-management and, maybe, some of our low-intensity psychological techniques is the how of doing that. There is much more to the ACT approach than this simple analogy. In the future, I hope that tested low-intensity ACT interventions will become available and taught to low-intensity practitioners in post-qualifying programmes; the approach is suited to this and other areas of low-intensity psychological work and practitioner’s existing skills would be enhanced by such a development.

Multistrand interventions in LTC Multistrand working is when the low-intensity practitioner implements a treatment intervention with a patient but is able to draw on additional strategies and techniques from the low-intensity toolbox when barriers arise to implementing the primary intervention. Sometimes it will involve delivering more than one intervention consecutively during a course of treatment, but more often, it will involve weaving theory and technique from the interventions together throughout the course of treatment. For example, a practitioner might be supporting a patient with insomnia to use a behavioural intervention to improve their sleep. If the patient came to an appointment and reported that they were following the treatment plan but that their sleep was still disrupted by worry (for example), the practitioner would be able to implement education on progressive muscle relaxation techniques or ‘worry time’ to overcome that barrier, before bringing the focus of treatment back to the primary intervention. Multistrand interventions have always been essential in LTC practice. We need to understand the strategies for managing depression and anxiety as well as the safe and simplest tools for the patient’s self-management of their physical health condition and be able to select between these strategies to best equip an individual for the complex task of self-management. The image below (Fig. 5.5) is an attempt to illustrate how a primary ‘strand’ of treatment will often need to be supported by additional principles to be delivered safely.

FIG. 5.5  How a primary intervention might be supplemented with additional strategies and theory in LTC work? (Credit: Original image.)

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New ideas It didn’t take long for us to realise that low-intensity interventions ‘business as usual’ was not safe for the patient population who live with LTCs. We had to learn additional strategies and support the traditional interventions with these. Pacing, deliberate integration of the ideas of valued activity, borrowed from Acceptance and Commitment Therapy, and Functional Equivalence, borrowed from the work of Lewis et al. on the University of York-led CASPER trial (Lewis et al., 2017) were essential safety and efficiency features in our work.

Pacing Pacing is the primary additional strategy that we had to be able to deliver with patients in this area of work. There is a large body of literature, particularly in rehabilitation focused journals, about pacing in various health conditions which I won’t repeat here. Pacing involves staying within the body’s ability to be active. This can involve reducing activity overall so that the body’s capacity for activity is never reached. Breaking activity into distinct tasks that can be completed at a slower pace, with breaks in between each task. It can involve the deliberate use of rest to protect and restore capacity for activity. It is an essential adaptation when working with patients who experience breathlessness, pain, and fatigue which can make it possible for the patient to engage in some activity without a crippling exacerbation of symptoms. We often introduced Christine Miserandino’s ‘Spoon theory’ to give a rationale for pacing and I recommend a quick internet search for some excellent resources and infographics about this explanation of limited activity in LTCs.

Valued activity An understanding of ‘valued activity’ enables us to work with the patient to find out which activities matter the most to them. ‘Values’ in this context are those parts of life that make life feel meaningful. Values are not achieved but are present as a theme, guiding who we want to be as people, what our life is ‘about’, and how we want to relate to other people. We tend to be most content and healthy when our behaviour is congruent with our values (Parisi et al., 2019). When a person is living with limitations on their ability to be active that are caused by a health condition, valued activity can be prioritised to make sure that the patient’s capacity for activity is being used to support their mood and protect against depression. This is essentially about getting ‘the most bang for your buck’ when you are using activity to affect mood.

Sarah: I love the values-based stuff. I found it quite hard to do with some elderly patients. It can be more challenging to explain the concept, but it’s always worth trying because of the potential benefits. For instance, when you’re doing values work with people with health conditions that lead to reduced activity, it can highlight why they’re depressed: because they really value, say, socializing or doing exercise but they can’t do it anymore.

Functional equivalence Functional equivalence, as used in the CASPER trial (Lewis et al., 2017), is a simple and useful tool to help patients who are no longer physically able to perform valued activity figure out replacement activity that will provide them with some of the same benefits. For example, someone who values their spiritual practice but can no longer attend a place of worship might examine what it was about attendance that mattered the most to them. Maybe it was the aspect of communal worship, the familiarity of the building and routine, the specific rituals and practice that take place there, an opportunity to catch up with old friends, and hear the news from the community. Once you have identified what an activity gave to you, you can look for alternative ways to gain some of the same benefits from activity that you are still able to complete. Maybe some friends from the community could visit your home to share the news and do a spiritual practice together? The alternatives can be endless.

In addition We also found that psychoeducation and time to think and reflect about communication, working with caregivers and health providers, relaxation skills, and a specific acknowledgement of the bio-psycho-social model as a way to recognise the huge and widespread impact and losses that are a consequence of physical health changes were very well received by patients within our LTC interventions.



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On kindness Kindness is a quality that we can communicate to each other with words and actions. It involves being friendly, considerate, and generous. Some people associate gentleness and compassion with kindness. In recent decades, we have seen a ‘third wave’ of CBT theory and practice emerge. The ‘third wave’ introduced process-, values-, and function-based understanding to the world of CBT practice. Buddhist principles, particularly the practice of mindful meditation, are often incorporated. The third wave includes Mindfulness Based Cognitive Therapy, Dialectical Behaviour Therapy, Acceptance and Commitment Therapy, and Compassion Focused Therapy, elements of which appear throughout the IAPT LTC programme. In this context, several models of compassion have emerged, but many theorists are broadly happy to accept His Holiness the Dali Lama’s definition of compassion: ‘a sensitivity to the suffering of self and others, with a deep commitment to try to relieve it’. I shared an account of my experience of the role of kindness in LTC work in a blog post on notaguru.blog in March 2021: ‘I’d worked as a psychological wellbeing practitioner (PWP)/low-intensity therapist (LIT) for a few years before I was given permission to talk about kindness in IAPT. In 2012/13 (ish), we were one of the pathfinder sites for long-term conditions and persistent physical symptoms adaptations in IAPT services across England. A local team of clinical and health psychologists was attached to our IAPT team to support us to adapt our interventions, as well as providing additional supervision and training. We worked with them to develop two low-intensity psychoeducation courses, one for chronic pain and one for generic long-term conditions. In session four of the pain course, we came to the slides on ‘Self-Compassion’. In my time in IAPT, I had never spoken about kindness, let alone self-compassion. How did it fit? Was I drifting? What on earth was I supposed to say? A big bit of me didn’t care. As I read Paul Gilbert and the slide notes that the clinical psychologist had written, I knew that these ideas were central to the practice of low-intensity psychological therapies, it made sense of everything. The years went by and our work, and my experience, progressed. We kept those slides on kindness in our courses; I spoke about them in training sessions and wrangled for them in clinical governance meetings. When we hit on a “final” version of the slides and material, my manager gave me a stern look. ‘We don’t talk about compassion-focused therapy; there’s no evidence base at step 2. This is just about basic human kindness’. Brilliant! We needed to be able to talk about this fundamental human need without forcing it into some kind of pseudo-scientific model (with heartfelt thanks to the CFT folks for doing the work that gave kindness enough validity for IAPT to include it!). It really didn’t matter what we called it as long as someone in an NHS badge spoke to people who were enduring suffering and told them it was OK not just to address the content of their automatic thoughts, but to consider how they felt and spoke towards themselves, and to do that with kindness. ‘The NHS says it’s OK for you not to beat yourself up. I’ll half-joke when I facilitate cognitive restructuring. The patient will snort-laugh, and you feel something in them ease’.

Bringing it together When we work with people who live with long-term health conditions, we are working with a group of people who have often experienced profound loss, who can feel frustrated and abandoned after prior experience of care. Our patients might have to establish new routines for self-monitoring and medication compliance, alongside that some will have to manage daily uncertainty and anxiety about their body. In this context, we must work with humility, caution, and compassion to enable that person to understand and learn how to manage their health and its impact on their whole life. We can adopt new ideas and adapt our ‘business as usual’ to understand and respect the limitations on function and mobility that can be imposed by altered physical health. We have a role in supporting the patient to acknowledge and accept the social and psychological effect of their health condition, and to do that without destroying hope that there could be advances in treatment and care in the future. It becomes important to identify a direction that the patient wants to move towards in their life and support them in the problem solving process as they adapt their activity to new abilities and demands.

Limitations As I have spoken to my colleagues, we have agreed on some risks when we adapt our work to this area. It’s easy to forget how very simple low-intensity interventions are. Because the models are generic, it is possible to capture a wide variety of experiences within them. This can lead to a false, usually unconscious belief that we know everything. Of course I’m exaggerating, but it is worth thinking about the times when we shouldn’t proceed with a low-intensity intervention before this chapter closes.

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Step up As much as a simple intervention can be the right help when a patient is managing complex problems, sometimes the mental health problem, or the way that the mental health problem interacts with the physical health condition, requires more time and a more complex and idiosyncratic formulation to guide an effective piece of work. That means that we need to know when to ‘step-up’ care to a counsellor, psychotherapist, or CBT practitioner, and we should never work in situations where the more intensive level of care is unavailable. The same guidelines apply for the management of depression and anxiety in the context of physical health conditions as when we are working with the mental health condition alone. We can offer some effective self-management strategies for mental health in low-intensity work, but treatment for complex, enduring, and severe mental health conditions won’t happen at the level of low-intensity care. LTC work can create some ambiguity in the recognition of mental health conditions that require expert use of good supervision and, often, consultation with other practitioners to figure out.

Reciprocal support It was my unfortunate experience to spend some time as a patient on a hospital ward during writing. After an inpatient experience of physical healthcare, I strongly suggest that some of the core values and competencies that we take for granted in low-intensity psychological interventions not just can but must be adopted in physical healthcare settings. The work that we completed locally with dual-trained practitioners and psychological practitioners integrated into physical healthcare teams demonstrated how effective the cross-pollination of training and skills can be. In our conversation, Sarah emphasised how helpful the new way of holding conversations with patients had been in her nursing practice. The dual-trained physiotherapists felt able to acknowledge the emotional aspects of their patient’s experience of musculo-skeletal conditions and chronic pain, which helped to engage the patient in treatment and self-­ management. Being able to use effective interpersonal skills to acknowledge the psychological aspect of a physical health difficulty does not require extensive training or create additional demands within the contact time that a patient requires from practitioners. A simple human-to-human acknowledgement of the subjective experience of a health experience or event can relieve anxiety, provide comfort, and ease some of the barriers that get in the way of compliance with treatment protocols. It would be a significant development if basic ‘active listening’ skills, empathy, and a knowledge of common mental health disorders was incorporated into all health and social care training. In return, psychological practitioners are in a good position to provide consultation and training on the interaction between the physical and psychological. We can provide training on clinical risk recognition and management and supervision of work that involves a psychological element of care.

Collaboration Liz: What would be your concluding message about training and using the PWP method? Sarah: I think collaboration has got to be the most important. A collaborative approach. So that you understand the problem from the patient’s perspective rather than how you see the disease. So I think it should be a patient-centred collaborative approach. And the bit that I always feel is the most different is that the patient’s going to do it, not you. … As a cultural tradition, we go to a nurse or a doctor with a problem, and the nurse or the doctor is supposed to provide the solution. So actually it’s about helping people realise that

they themselves have got the solution. And how do you help them? How do you facilitate that? How do you facilitate a solution for somebody rather than giving them an instruction? A lot of the skills within the PWP framework are about facilitating. If a patient needs to reduce their dependence on an inhaler, you could simply say “Only use your inhaler six times a day instead of eight times.” But, if you teach them breathing techniques instead, you’re facilitating a solution. Liz: So you’re adding something in rather than taking something out. You’re not limiting them; you’re adding something into the picture and hoping that the balance moves itself around a bit. Sarah: Yes It’s about empowering people, isn’t it?

A possible future? The concept of integrated care has been central to the expansion of IAPT Low-Intensity Therapies into physical healthcare. Integration is a co-ordination between physical and mental healthcare that smooths out some of those difficulties that I have described above.

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To bring this chapter to a close, I’d like to give you something to aim for and celebrate the great work that is already happening in this area. This is an example of what I hope that the learning in this chapter will nudge us towards. Imagine that you are a low-intensity practitioner. Instead of holding your clinic in an isolated room in a GP practice or an IAPT office, or at home in the postpandemic world, you work part of your week in a custom designed community wellbeing centre. Let’s take a tour of the building. There is a suite of modern medical/clinical rooms along one corridor; in these rooms there are ● ● ● ● ● ● ●

clinics from the local pain management team staffed by senior physicians; musculo-skeletal team and physiotherapy; occupational therapists (including equipment and adaptations and mental health specialists); psychologists from local hospital departments; IAPT/primary care psychological therapies; the local equivalent of a single point of access for mental health services; community nurses. On top of this, there are:

●

● ●

● ● ●

●

● ●

●

●

Interpreters who speak the most commonly used local languages employed at the site several days a week (ideally the physical and healthcare teams would have bi-lingual practitioners within them, or employ consultants from their local communities to support adapted care). A large and well-equipped gym fills most of the first floor. Gym membership is discounted for patients who are accessing one of the teams who hold clinics in the building and health trainers are available to all members. A swimming pool that holds women only sessions and autism aware/quiet sessions is on the ground floor. There’s a lovely café in the large and welcoming atrium. Citizen’s advice, occupational health and employment services, and community support workers are available a couple of times a week. Local third-sector organisations who run horticultural therapy projects, healthy eating programmes, and a choir regularly have representatives in the café area for anyone who wants a chat. There’s an English conversation café and a craft club twice a week. Peer support groups for people who live with a variety of long-term physical and mental health conditions meet their regularly. Facilities include large rooms that are used to run classes that low-intensity practitioners and physical health practitioners co-facilitate to answer the most common questions and worries, and teach self-management skills for long-term conditions. This fully accessible community centre is used by people from across the full spectrum of age and mobility and it was purpose-designed to feel relaxed and welcoming, whilst making movement feel safe and normal.

During the working days on this site, the low-intensity practitioner is on an honorary contract with one of the physical health teams, working under their governance as well as the IAPT governance process and receiving supervision and guidance from the physical healthcare practitioners around the physical health symptoms that their patients present with alongside depression and anxiety. In turn, the low-intensity practitioner provides supervision and guidance for the physical healthcare team on how to recognise and manage symptoms of depression and anxiety.

Outcomes Although not an exact representation of what is happening, we have trailed this sort of arrangement and my goodness, it was pretty good. Patients ● ●

Did not have to travel to new settings to access physical and psychological care. Were assured that the team was working cohesively to provide the care that they needed. As a low-intensity practitioner who was essentially seconded into a physical healthcare team for 1 day a week:

● ●

I had easy access to the notes and consultation that I needed to make my work safe. I could gain enough insight into the physical aspect of a patients’ health condition and how their physical healthcare was managed that I could effectively support self-management.

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Physical healthcare practitioners ● ●

Had quick access to a repository of information about mental health conditions and care provision (that was me!). Could ask for support when they felt uncertain about the psychosocial elements of a presentation.

All ●

Received care and/or practised in a welcoming, community-focused environment where physical and mental health teams could share expertise and patients benefited from many of their needs being met under one roof.

You can read a summary and see some short videos about some of this work on the NHS.UK website under mental health case studies with a title ‘Chronic pain and low back pain pathway at Sheffield Improving Access to Psychological Therapies (IAPT) Service’ (https://www.england.nhs.uk/mental-health/case-studies/improving-access-to-psychologicaltherapies-iapt-case-studies/chronic-pain-and-low-back-pain-pathway-at-sheffield-improving-access-to-psychologicaltherapies-iapt-service/).

What could happen in the future? There is an important role for psychological care that is integrated into physical healthcare. Psychological care that is provided to people who live with chronic health problems must be supported and informed by medical guidance and adapted to the physical reality that patients live with. Sometimes psychological practitioners must step aside and allow medical care to be the priority when it is available. In an ideal world, wherever health and social care is provided, it would be holistic; the patient shouldn’t be required to chop themselves into pieces and ignore important facets of their experience to work with a professional. Ideally an awareness of the psychological and social effects of changes in physical health would be embedded into physical healthcare training, and psychological services would be integrated into physical healthcare settings. Can we adopt the agility to work together to provide services that respond to changing knowledge; that alleviate emotional distress, support processes of grief and acceptance, coach in self-management as long as a ‘cure’ isn’t available, and reduce barriers to compliance with treatment when a medical intervention is available? That’s the dream.

References Abbas, A., Lumley, M.A., Town, J., Holmes, H., Luyten, P., Cooper, A., Russell, L., Schubiner, H., De Meulemeester, C., Kisely, S., 2021. Short-term psychodynamic psychotherapy for functional somatic disorders: a systematic review and meta-analysis of within-treatment effects. J. Psychosom. Res. 145. https://doi.org/10.1016/j.jpsychores.2021.110473. Boyd, K.M., 2000. Disease, illness, sickness, health, healing and wholeness: exploring some elusive concepts. Med. Humanit. 26, 9–17. Care Quality Commission, Public Health England, National Health Service, 2015. Five Year Forward View. NHS. Centers for Disease Control and Prevention, 2018, October 31. Well-Being Concepts. Centers for Disease Control and Prevention. Retrieved September 3, 2022, from https://www.cdc.gov/hrqol/wellbeing.htm. Deary, V., 2005. Explaining the unexplained? Overcoming the distortions of a dualist understanding of medically unexplained illness. J. Mental Health 14 (3), 213–221. https://doi.org/10.1080/09638230500136605. Edwards, A., Santhosh, S., Kunorubwe, T., 2022. Cultural change in IAPT—a work in progress. CBT Today 50, 24–28. Frontline, 2015. 3 Minutes with Nicola Willcocks. Frontline Retrieved September 3, 2022, from https://www.csp.org.uk/frontline/ article/3-minutes-nicola-willcocks. Geraghty, K., Scott, M.J., 2020. Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified. BMC Psychol. 8 (1), 13. https://doi.org/10.1186/s40359-020-0380-2. Gilio, L., Galifi, G., Centonze, D., Stampanoni Bassi, M., 2021. Case report: overlap between long COVID and functional neurological disorders. Front. Neurol. 12, 811276. https://doi.org/10.3389/fneur.2021.811276. Huber, M, Knottnerus, JA, Green, L, van der Horst, H, Jadad, AR, Kromhout, D, Leonard, B, Lorig, K, Loureiro, MI, van der Meer, JW, Schnabel, P, Smith, R, van Weel, C, Smid, H, 2011. How should we define health? BMJ 343, d4163. https://doi.org/10.1136/bmj.d4163. Kellett, S., Webb, K., Wilkinson, N., Bliss, P., Ayers, T., Hardy, G., 2016. Developing services for patients with depression or anxiety in the context of long-term physical health conditions and medically unexplained symptoms: evaluation of an IAPT pathfinder site. Behav. Cogn. Psychother. 44 (5), 553–567. https://doi.org/10.1017/S1352465816000114. Lewis H, Adamson J, Atherton K, et al. CollAborative care and active surveillance for Screen-Positive EldeRs with subthreshold depression (CASPER): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness. 2017. Health Technology Assessment, No. 21.8. Available from: https://www.ncbi.nlm.nih.gov/books/NBK424703/. Ludman, E.J., Peterson, D., Katon, W.J., Lin, E.H.B., Von Korff, M., Ciechanowski, P., Young, B., Gensichen, J., 2013. Improving confidence for self care in patients with depression and chronic illnesses. Behav. Med. 39 (1), 1–6. https://doi.org/10.1080/08964289.2012.708682.



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Maksoud, R., Balinas, C., Holden, S., Cabanas, H., Staines, D., Marshall-Gradisnik, S., 2021. A systematic review of nutraceutical interventions for mitochondrial dysfunctions in myalgic encephalomyelitis/chronic fatigue syndrome. J. Transl. Med. 19 (1), 81. https://doi.org/10.1186/s12967-02102742-4 (PMID: 33596913; PMCID: PMC7890871). McCrae, N., Correa, A., Chan, T., Jones, S., de Lusignan, S., 2015. Long-term conditions and medically-unexplained symptoms: feasibility of cognitive behavioural interventions within the improving access to psychological therapies program. J. Ment. Health 24 (6), 379–384. https://doi.org/10.3109 /09638237.2015.1022254. McLaren, N., 1998. A critical review of the biopsychosocial model. Aust. N. Z. J. Psychiatry 32 (1), 86–96. https://doi.org/10.3109/00048679809062712. Napier, A.D., et al., 2017. Culture Matters: Using a Cultural Contexts of Health Approach to Enhance Policy-Making. World Health Organization. National Collaborating Centre for Mental Health, 2021. The IAPT Manual. Available online https://www.england.nhs.uk/wp-content/uploads/2018/06/ the-iapt-manual-v5.pdf. National Institute for Health and Care Excellence. 2021. Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management. NICE guideline [NG206]. https://www.nice.org.uk/guidance/ng206. NHS, n.d. Integrated care. NHS choices. Retrieved September 3, 2022, from https://www.hee.nhs.uk/our-work/integrated-care. Ogunbayo, O.J., Schafheutle, E.I., Cutts, C., et al., 2017. Self-care of long-term conditions: patients’ perspectives and their (limited) use of community pharmacies. Int. J. Clin. Pharm. 39, 433–442. https://doi.org/10.1007/s11096-016-0418-y. Padesky, C.A., 2020. Collaborative Case Conceptualization: Client Knows Best. Cognitive and Behavioral Practice. Available online 23 July 2020, https:// doi.org/10.1016/j.cbpra.2020.06.003. Parisi, J.M., Roberts, L., Szanton, S.L., Hodgson, N.A., Gitlin, L.N., 2019. Valued activities among individuals with and without functional impairments: findings from the National Health and Aging Trends study (NHATS). Act. Adapt. Aging 43 (4), 259–275. https://doi.org/10.1080/01924788.2018.15 21254 (Epub 2018 Oct 5. PMID: 32362702; PMCID: PMC7194186). Personalised Care Group, 2018, April 4. Module 1: Pam - NHS England. Retrieved September 3, 2022, from https://www.england.nhs.uk/wp-content/ uploads/2018/04/patient-activation-measure-quick-guide.pdf. Raleigh and Holmes, 2021. The Health of People from Minority Groups in England. Kings Fund. https://www.kingsfund.org.uk/publications/ health-people-ethnic-minority-groups-england. Rimes, K.A., Wingrove, J., Moss-Morris, R., Chalder, T., 2014. Competences required for the delivery of high and low-intensity cognitive behavioural interventions for chronic fatigue, chronic fatigue syndrome/ME and irritable bowel syndrome. Behav. Cogn. Psychother. 42 (6), 760–764. https://doi. org/10.1017/S1352465814000290. Seaton, N., Moss-Morris, R., Norton, S., Hulme, K., Hudson, J., 2022. Mental health outcomes in patients with a long-term condition: analysis of an improving access to psychological therapies service. BJPsych Open 8 (4), e101. https://doi.org/10.1192/bjo.2022.59 (PMID: 35640903; PMCID: PMC9230614). Sharpe, M., Chalder, T., White, P.D., 2022. Evidence-based care for people with chronic fatigue syndrome and myalgic encephalomyelitis. J. Gen. Intern. Med. 37 (2), 449–452. https://doi.org/10.1007/s11606-021-07188-4. Taylor, S., Pinnock, H., Epiphanou, E., Pearce, G., Parke, H., Schwappach, A., et al., 2014. A rapid synthesis of the evidence on interventions supporting self-management for people with long-term conditions (PRISMS practical systematic review of self-management support for long-term conditions). Health Serv Deliv Res 2 (53). https://doi.org/10.3310/hsdr02530. World Health Organization., 2002. Innovative Care for Chronic Conditions: Building Blocks for Actions: Global Report. World Health Organization. https://apps.who.int/iris/handle/10665/42500. WHO Interim Commission, 1948. Official Records of the World Health Organization No. 2: Summary Report on Proceedings, Minutes and Final Acts of the. World Health Organization, Geneva. Zinn, M.A., Jason, L.A., 2021. Cortical autonomic network connectivity predicts symptoms in myalgic encephalomyelitis/chronic fatigue syndrome (ME/ CFS). Int. J. Psychophysiol. 170, 89–101. https://doi.org/10.1016/j.ijpsycho.2021.10.004.

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Chapter 6

Working inclusively with gender and sexual diversity James Spiers During the first half of this chapter, I will outline key background and historical issues that have impacted the LGBT community, both within wider society and within psychology and psychotherapy. Whilst this portion of the chapter takes on a more academic tone, it attempts to condense and draw together a large body of existing research and knowledge available in the public domain that is rarely included in low-intensity psychological therapy training. The aim here is to offer insight and learning for low-intensity practitioners, service leaders, and commissioners who may have limited experience and knowledge of the LGBT/queer community. The second half of this chapter will then offer a reflective case study based on my own low-intensity clinical work during my time in the IAPT programme. The aim here is to provide a realistic account of what happened rather than a how-to guide. Whilst it can be common in low-intensity practice (and beyond) to want manuals and step-by-step guides, I hope to demonstrate throughout this chapter that it is overly relying on manuals and the tendency to want to fit people into clearly defined protocols or models that can create problems when trying to offer inclusive practice. Essentially, to be more inclusive of all people in our society, we need to de-manualise, not create new ones. I am encouraging practitioners and services to reflect on their own thoughts and actions, whilst also encouraging more openness to be guided by the people that sit in front of you in your clinic rooms. My hope here is that posing reflective questions as opposed to guidelines will lead to further development beyond the reading.

Being queer Historically, the word ‘queer’ has been used as a pejorative term aimed at lesbian, gay, bisexual, and transgender (LGBT) people, more recently reclaimed by the LGBT community as a term that expresses the more fluid and nuanced experience of gender and sexuality that fit less neatly into L, G, B, or T group identities. Queer theory is a critical, multitheoretical concept that challenges the dominance of heteronormativity and binary sex and gender norms within psychological, social, and political discourses around sexuality and gender (Mayo, 2017; Nadal and Scharrón-del Río, 2021; Riggs, 2007). For the purpose of readability, I will use the terms lesbian, gay, bisexual, and transgender (LGBT), queer, interchangeably. This is not in any way an attempt to undermine or devalue the varied and rich expressions that people use to describe their identity, including fluid representations of both gender and sexuality.

Reflective learning task The content and concepts addressed in this chapter are likely to be emotive, and it is important that you can look after yourself, but I would also ask you to consider and reflect on the following questions where you feel able to. 1. Do you practise with reflection on your own biases, beliefs, and values? 2. Is an awareness of your biases enough to make your healthcare service accessible and are you and your service actively inclusive? 3. Does your healthcare service engage in outreach within your local communities and are they integrated with other services, offering linkage to a range of access opportunities such as digital and remote options? 4. Do you actively seek to consider the history of those whose journey to therapy may include additional barriers to engagement?

Care in High Volume. https://doi.org/10.1016/B978-0-323-88492-1.00006-3 Copyright © 2023 Elsevier Inc. All rights reserved.

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Construction and deconstruction of LGBT identities in psychotherapy Historical issues concerning sexual and gender differences in psychiatry and psychotherapy have seen major shifts in understanding and approach, often paralleled with political and social change. Freud’s writings, in Three Essays on the Theory of Sexuality (Freud, 2017), whilst situated in time and context, were arguably more aligned with contemporary psychodynamic thinking, in that gender and sexual differences are a normal part of human life, but oppressive social attitudes that contribute to minority stress are likely to impact on the psychological health and interpersonal functioning of people belonging to LGBT groups (Lingiardi and McWilliams, 2017, p. 237). However, prominent mid-20th-century theorists considered homosexuality to be a perversion of normative psychosexual development, leading to openly LGBT people being excluded from training in psychiatry or psychotherapy (Drescher, 2008). The dominating narrative throughout the post-Freudian mid-20th century was one of abnormality, subsequently leading to gender and sexual differences being categorised in the Diagnostic and Statistical Manual (DSM) of mental health disorders (American Psychiatric Association, 1952, 1968). The first edition of the DSM (American Psychiatric Association, 1952) termed sexual diversity a ‘sociopathic personality disturbance’, undergoing re-categorisation in the second edition (DSM-II; American Psychiatric Association, 1968), to ‘sexual deviation’. The association between sexual orientation differences and psychopathology continued until the latter half of the 20th century when homosexuality was eventually de-categorised as a psychiatric condition in the revision of DMS III (American Psychiatric Association, 1973). The International Classification of Diseases (ICD-10; World Health Organization, 1992) eventually took a similar path. Psychiatric constructs of transgender identity persisted until the publication of the fifth edition of the DSM (American Psychiatric Association, 2013), where recognition of the psychological and emotional distress that can be experienced as a result of gender incongruence (a person’s gender identity is different to that of their biological sex assigned at birth), termed gender dysphoria, replaced the prior categorisation of gender identity disorder as a mental health condition (Drescher, 2016). The World Health Organization has since proposed to go a step further in removing ‘gender dysphoria’ in the upcoming ICD-11 classification of mental health disorders, recognising diverse gender identity and transition as a ‘Condition Related to Sexual Health’ in an attempt to disassociate it from mental health pathology.

‘Conversion’ therapy There have also been persistent attempts throughout the history of psychiatry and psychology to convert different gender and sexual identities to those of cisgender heterosexual norms through so-called ‘Conversion Therapy’. These have included aversive behavioural and cognitive attempts to modify sexual orientation and gender identity ranging from physical interventions such as vomit-inducing drugs, chemical castration, electroconvulsive therapy (ECT), and lobotomy (Messinger, 2006), to emotional, spiritual, and psycho-social approaches (Jowett et al., 2021). Mostly, attempts to modify or ‘convert’ gender and sexual identity are considered ineffective (Jowett et al., 2021) and more likely to lead to worse mental health outcomes (Asquith et al., 2020; Jowett et al., 2021), as well as increasing the likelihood of suicide and self-harm, as opposed to improving wellbeing (Asquith et al., 2020) . Attempts to convert gender or sexual identity are currently banned practice across most of the major bodies for counselling, psychotherapy, and psychology, including the American Psychiatric Association (2021) and the British Psychological Society (2021). However, Stonewall (Somerville, 2015) claim that around 10% of UK health and social care staff reported having witnessed colleagues admitting that they believe people can be ‘cured’ of their diverse sexual or gender identity. Approximately 2% of UK LGBT people reported having undergone some form of conversion therapy, and 5% said they have been offered conversion therapy through spiritual and psychological approaches, including from family members (Jowett et al., 2021), with 15% of UK therapists admitting to having previously delivered counselling or psychotherapy to reduce same-sex attraction or sexual orientation (King, 2015).

Age as a factor in LGBT experiences The United Kingdom has also seen significant changes in the social and political landscape over a relatively short period of time in terms of legislative and social discourses around gender and sexual diversity. For example, prior to the Sexual Offences Act (1967), it was illegal to engage in sexual acts with another person of the same biological sex assigned at birth. The consequence of acting on someone’s same-sex attraction or sexual orientation prior to the decriminalisation of homosexuality in the United Kingdom included a financial penalty, custodial sentence, or a psychiatric treatment order to avoid a custodial sentence (Jowett et al., 2021).



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During the height of the acquired immunodeficiency syndrome (AIDS) pandemic in the 1980s/’90s, the human immunodeficiency virus (HIV) was circulating as a highly contagious sexually transmitted disease that initially spread amongst gay men, leading to eventual serious illness and death from pneumonia and cancers due to the compromised immune system as a result of AIDS. Whilst medicine has seen significant advances in HIV treatment in recent times, the pace of research into medical therapeutics was initially slow, with millions of people from the LGBT community dying due to a lack of therapeutics (Dentato et al., 2014). The British media and subsequent social narrative at the time became one of HIV and AIDS being a gay man’s disease, with significant discrimination and social aggression being directed towards the LGBT community (Messinger, 2006). The legacy of a relationally traumatic social response is still thought to be remembered viscerally by many in the LGBT community to this day. LGBT people in the United Kingdom will also likely have experienced elements of their social and cognitive development during a period of legislation called Section 28 (1988–2003) in response to the AIDS pandemic. This was legislation brought in under the Conservative leadership of Margaret Thatcher, effectively banning materials from public view that related to gender and sexual diversity, including educational materials in schools and libraries. The aim of the legislation was cited as a move to protect children from being influenced towards an LGBT lifestyle. However, some of the children growing up with different gender and sexual orientation under Section 28 (and now adults) have reported adverse effects on their psychological wellbeing and claim that this was a result of having a lack of access to material about LGBT or queer experiences during their early life (Wilson et al., 2018). Age differences have also been reported to impact the LGBT community, from intraminority discrimination (within the LGBT community) stemming from ageism (Detwiler, 2015) to the preliminary findings and reported client satisfaction in a trial group intervention using adapted CBT to include LGBT experiences (Lloyd et al., 2021). Some of the participants involved in the trial stated that they felt unable to relate to each other's experiences due to wide differences in the age range of participants.

Social relationships: Power and intersectionality Intersectionality is the theory that the greater the diversity of characteristics a person holds, the higher the likelihood that the person will experience discrimination and lower social power within society, leading to social disadvantage, see Cole (2009).  Discrimination can occur at the interpersonal level, where negative experiences result from our interactions with others (Shin et al., 2017). At the intrapersonal level, where societal discrimination and microaggressions are internalised (Meyer, 2003). Discrimination can also occur within institutions and organisations, where policies and practices are determined based on societal norms that can generate both explicit and implicit barriers to public services, leading to inequitable access and opportunity (Cole, 2009; Shin et al., 2017). Yet, intersecting aspects of identities, including socioeconomic and professional status are likely to lead to different individual experiences, particularly when considering social power within the context of heterocentric social norms (Mayo, 2017; Nadal and Scharrón-del Río, 2021; Riggs, 2007). For example, aspects of identity that are minoritised by the dominance of majority social identities, e.g., people with disability, Black, Asian, Minority Ethnic, noncisgender, and nonheterosexual identities, versus privileged aspects of identity such as being able bodied, a cisgender male, university educated, and speaking English as a first language (Turner, 2021). The relevance of intersectionality here is that it is unlikely that people who may hold some shared aspects of their identity, e.g., gender expression and sexual orientation, will experience the social world, including the degree and prevalence of social advantage and disadvantage, in the same way as another, or have the same lived experience despite similarities in their social context. Essentially, as individual humans, we hold more to our unique identity than sexual orientation and gender.

Minority stress modelling The Meyer (2003) Minority Stress model (Fig. 6.1) draws on collective experiences that people with shared gender and sexuality differences may commonly encounter throughout the lifespan whilst also accounting for intersectional differences. The model is conceptualised using separate but interconnected aspects of experiences related to distal stress (external experiences such as discrimination, oppression, and aggression) and proximal stress (related to internal experiences including self-critical beliefs) that can impact on mental health outcomes. According to Meyer (2003), both distal and proximal LGBT minority stress can impact mental health and interpersonal functioning, but outcomes may be potentially mediated by individual resilience (personal capacity for coping with distress) and social support (interpersonal relationships), such as belonging to a peer or community group.

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FIG. 6.1  Interconnected experiences that contribue to LGBTQ+ minority stress. (Adapted from Minority Stress Model. Meyer, I.H., 2003. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol. Bull. 129(5), 674–697.)

LGBT access and outcomes in mainstream UK psychological services Disparities in the wider general population relating to the treatment of common mental health problems such as anxiety and depression led to the implementation of the Improving Access to Psychological Therapies (IAPT) programme under the Labour government in 2008 (Clark et al., 2009, 2018). Since the inception of IAPT, mental health care accounts for around a quarter of the clinical activity in the National Health Service (NHS England, 2019) and the ‘five years forward’ initiative is tasked with providing ‘good quality care for all by offering the right care at the right time’ (NHS England, 2019, p. 11). Mainstream primary care psychological services such as IAPT are attempting to increase their reach to 25% of the national population by 2024 (NHS England, 2019). To achieve equitable access and outcomes for all, this includes expanding the reach of IAPT to those who belong to minoritised groups, see The National Collaborating Centre for Mental Health (2021). Large-scale data sets from the IAPT programme show that proportionate numbers of people (approximately 3% of the population in England) with different gender and sexual identities (Office for National Statistics, 2019) access a mainstream psychological service such as IAPT (Baker, 2018; Clark et al., 2018). Yet, there is evidence to indicate that the demographic data captured, proportionate to people with gender and sexual difference, are less clear. It is anticipated that around 19% of people identifying as LGBT are not out to any healthcare professional about their sexual orientation when seeking health care. This number rises to 40% for bisexual cisgender men and 29% for cisgender bisexual women, with one in seven LGBT people reporting that they actively avoid seeking health care for fear of discrimination from healthcare staff (Bachmann and Gooch, 2018a; Somerville, 2015). Similar figures have been found in primary care psychotherapy, with over a third of LGBT people actively not disclosing their sexual identity, and over half stating that they had not actually been asked about their gender or sexual identity by their healthcare provider (Foy et al., 2019). Approximately 50% of LGBT people report symptoms of depression (Bachmann and Gooch, 2018a) compared with around 25% of the general population (Office for National Statistics, 2017) and appear to be more likely to experience problems with substance use, suicidal ideation, and self-harm (Bradlow et al., 2020; Plöderl and Tremblay, 2015; Semlyen et al., 2016). There is also some evidence to suggest that LGBT groups access healthcare services more frequently with problems relating to psychological wellbeing (Chakraborty et al., 2011; Cochran et al., 2017; Filice and Meyer, 2018) but are less likely to achieve positive outcomes in primary care psychological services when compared to cisgender heterosexual groups (Moller et al., 2019; Rimes et al., 2018, 2019).

Outcomes: Considering therapeutic paradigms Cognitive behavioural therapy (CBT) is commonly recommended in mainstream NHS psychological services. The emphasis of CBT is a time-limited targeted intervention to alter patterns of thinking and behaviour that maintain problems with anxiety, depression, and compulsion. Whilst there is limited research surrounding the efficacy of CBT when working with minority groups, the impact of social attitudes and early environment that may lead to internalised social messages, self-critical beliefs, and poor self-evaluation have been proposed as key adaptations when working with LGBT clients



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(Pachankis et al., 2015a, 2020). Implying that both therapists and services might be less well placed to meet the needs of LGBT clients unless they are explicitly open to addressing societal issues and the influence and impact of minority stress. Most mainstream primary care services such as IAPT offer a range of therapeutic modalities, including low-intensity CBT (LICBT), cognitive behavioural therapy (CBT), as well as relational and emotionally focused therapies such as interpersonal therapy (IPT), dynamic interpersonal therapy (DIT), and person-centred experiential therapy (PCET) (Clark et al., 2018; The National Collaborating Centre for Mental Health, 2021. Whilst there is currently limited research that explains disproportionate outcomes for LGBT groups, there is currently little to no evidence to suggest that disproportionate outcomes are based on the therapeutic modality alone. Whilst people who identify as LGBT may be less likely to resolve problems with anxiety and depression with lowintensity intervention (Rimes et al., 2019), bisexual groups, and lesbian women were considered to be at the most increased risk of poor recovery outcomes even when controlling for session length and intensity of the intervention (Rimes et al., 2018, 2019). However, caution is needed when interpreting such data given the limitations on the reporting of sexual and gender identity demographic information within mainstream services (Foy et al., 2019), small effect sizes (Rimes et al., 2018, 2019) and the availability of participant data primarily being within White younger adult age groups. There is also limited research relating to therapeutic outcomes based on gender and sexual differences in secondary and specialist psychological services. One of the few available studies is Beard et al. (2017) who found no significant differences in therapy outcomes between LGBT and non-LGBT participants when comparing CBT with dialectical behavioural therapy (DBT) skills (Linehan, 2014). However, bisexual individuals were more likely to report problems with self-harm and lower satisfaction with treatment. It is also important to note that research with transgender experiences in mainstream services is sparse. Hypotheses that have been put forward here consider the potential for associations that may still exist within the LGBT community that relate to the history of psychology and psychiatry in terms of mental health and gender transition. Further, Bachmann and Gooch (2018b) imply that large survey data from Stonewall suggest that people with transgender identities are less likely to report mental health problems for fear of having their medical care withheld or withdrawn when approaching medical transition. Yet, qualitative research more commonly points to relational factors and LGBT affirmative approaches being reported as positively impacting LGBT clients’ experiences of counselling and psychotherapy (Davies and Neal, 2000; King et al., 2007). It is argued that therapists who aim to decentralise the location of problems from being identified within the individual, help LGBT clients make sense of their experiences within the context of social attitudes and minority stress (Nadal, 2019). Participants who undertook therapy with a therapist who held an affirming stance towards the client’s LGBT identity were found to report higher satisfaction with therapy (King, 2015). Offering a validating space to include discussion around the impact of likely minority stress experiences encountered by LGBT clients has also been cited as holding positive therapeutic value (Bochicchio et al., 2020; Pachankis et al., 2015b; Sheinfil et al., 2019).

The journey to therapy as LGBTQ+ Approximately 40% of LGBT individuals report fearing negative responses from clinicians in mainstream psychotherapy services, whether perceived or experienced (Foy et al., 2019), with around one in seven people from the LGBT community stating that they actively do not seek help for this reason (Somerville, 2015). Other factors that have been reported to impact the experience of approaching mainstream psychotherapy services include a fear that staff will lack awareness and training around common minority stress experiences, psychopathology being automatically assumed to relate to gender and sexuality, and clinicians neglecting to include gender and sexual identity in their clinical work (Foy et al., 2019). There are also increasing numbers of young people who are seeking sanctuary in Britain, Europe, and the United States, fleeing oppression, persecution, or potential death from their country of origin due to their sexuality or gender identity (House of Commons, 2019). Additional barriers to accessing mainstream psychological therapy services may include increased intersectional differences such as communication and language differences, cultural differences and understanding around the concept of mental ill health, and potential challenges with social integration (Fox et al., 2020).

LGBT visibility: Reducing access barriers? A common narrative surrounding what might improve the experiences of LGBT people in mainstream services is a higher visibility of LGBT clinicians (Foy et al., 2019) with similar findings reported in the United States (Israel et al., 2011) and Malaysia (Zay Hta et al., 2021). This was also a key finding from my own survey data and thematic analysis. A logical explanation here might be that LGBT people might feel less fear around the potential judgement and criticism of their

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gender or sexual identity through the increased likelihood of meeting with a clinician who is more likely to have a lived understanding and experience of minority stress related to gender and sexual difference. Yet, intraminority discrimination is rife within the LGBT community. Transphobia is commonly reported by people with transgender identities from the lesbian, gay, and bisexual (LGB) communities (Nadal, 2019). Disability discrimination is also reported, ranging from accessibility concerns to body image and shaming (Atkins, 2012), as well as biphobia (Pachankis et al., 2015b, 2020), high incidences of racism (Le et al., 2021), and ageism (Detwiler, 2015), implying that meeting a clinician who openly expresses diverse sexuality or gender identity comes with no guarantee of entirely removing biases, beliefs, attitudes, and actions that might lead to explicit or implicit discrimination or judgement, particularly for those where sexuality, race, disability, and gender identity intersect. Nor, the potential that their experience with an LGBT clinician will not result in feelings of rejection and shame. There is also the safety and comfort level of LGBT clinicians to consider when asking them to be visible in the workplace, particularly high-throughput services such as IAPT, given that out clinicians may also fear social aggression and microaggressions (Lea et al., 2010; Porter et al. 2015) as those who are seeking help for a mental health problem. Bullying and discrimination have also been reported by around a quarter of LGBT staff working in health and social care (Somerville, 2015), as well as minority stress due to social attitudes and beliefs. Here, the implications of increasing trainee representation of the LGBT workforce in mainstream NHS psychotherapy and counselling are also likely to be complex. For example, the average time for psychological therapy training from start to finish can range from 1-year postgraduate courses, e.g., IAPT psychological wellbeing practitioner (PWP) or high-intensity (HIT) CBT therapists (British Association for Cognitive and Behavioural Psychotherapy, 2021; University College London, 2021), to upward of two to four-plus years for counsellors, psychologists, psychoanalytic, or psychodynamic psychotherapists (British Association of Counselling and Psychotherapy, 2016; United Kingdom Counsel for Psychotherapy, 2021), as well as ethical and interpersonal considerations relating to the requirement of personal self-disclosure that would not be necessary for cisgender heterosexual therapists.

Affirmative practice Affirming psychotherapeutic practice can be delivered by any practitioner, provided that they are willing and open to working in this way. An affirming LGBT stance is not about dancing around the room telling the person how wonderful they are, it simply falls back to the very basics of the common interpersonal factors in building a strong therapeutic alliance (Roth and Pilling, 2008). For example, self-reflecting on biases, understanding what we, as clinicians, might be bringing to the therapeutic space and reflecting on our own experiences and values and how these might be in the way of understanding the person sitting in front of us. We also need to provide psychologically safe spaces in order that the person can feel safe enough to fully express themselves, but the addition here is that we also need to do the work to inform ourselves about the potential struggles that particular groups of people may face and be open to learning from our patients, being curious about their history and experiences (Beck et al., 2019; King, 2015; King et al., 2007). The labour here needs to be shared and community engagement and outreach will be essential to informing service adjustment and adaptation (Beck et al., 2019). So why is all this important for a low-intensity practitioner to know? Surely low-intensity practitioners are only treating the symptoms of anxiety and depression using guided self-help regardless of how the person came to seek treatment? If low-intensity practitioners treat everyone the same using a standardised evidence-based model, then surely they are practising inclusively?

Active inclusion vs inactive tokenism My own experience in low-intensity practice was that the fast-paced, high-volume nature of the work does not lend itself well to truly inclusive practice. First, there is little time to think during the working day as it is, and this is before you begin to approach discussing differences and adaptations during the very limited time of case management supervision and group-based clinical skills. Considering that the typical low-intensity practitioner will offer around 20 clinical hours per week, based on 45-min assessment sessions, 30-min treatment sessions, and around 15 min to review patients who are using digital interactive programmes, a low-intensity caseload can exceed 60 people upward. Bringing 15–20 cases per weekly case management session leaves around 3–4 min to discuss each case. A combination of time poor, heavily burdened clinicians leaves little time for development or learning, let alone community outreach and engagement. Working with differences in low-intensity psychological therapy is challenging, no two people will ever be the same, and we are highly likely to get things wrong. However, it is vital that we continue to learn and continue to be active, continuously improving and developing practice to include diversity and difference within our services and individual practice. By active I mean that we need to consider what is actually being done by services to include people with difference, as op-



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posed to what is being said and seen to be being done during team meetings and service conferences. More often than not, the appearance of inclusion, or ‘inclusive speak’ can mask services that more commonly remain inactive when it comes to diversity and difference. The majority of my experiences in both primary and secondary care services (charity, third sector, and NHS) is that they make lots of noise about inclusion, including many discussions that send ripples of narrative that sound like things are being done to address problems with access and outcomes for marginalised communities. Yet, for the most part goes no further than passive noise and performative action. The most common example that I’ve seen in IAPT services is the [insert area requiring improvement] ‘champion’.

The LGBT champion More explicitly relating to disproportionate access and outcomes for LGBT people in IAPT services, the LGBT champion is typically a very well-meaning member of staff who puts themselves forward to take a lead on LGBT issues within their team or service. It is important to note here that taking on any ‘champion’ tasks within very pressured and busy mainstream services is absolutely admirable. More often than not, there is no additional pay, time, or support allocated to the person. Commonly, or at least that is the most common experience I have witnessed in IAPT services, any additional work that is required outside of the pursuit of achieving the main key performance indicators (KPIs) within the core service activity, typically ends up being done in the staff members’ own time. Essentially, my critique here is not of the individuals that offer additional labour to try to improve health care for marginalised groups, showing considerable initiative and leadership, but of the systems that hold the accountability for equitable access and outcomes, poorly supporting the people who are trying to do the important work. So what does inactive inclusion via the ‘LGBT Champion’ look like in practice? A clear example that I have witnessed in several services in the North of England was either clinical or nonclinical staff mostly going about their general day-today role in the IAPT service but would task themselves with keeping an up-to-date database of signposting information and local LGBT resources. The database can then be accessed by the rest of the team or service in order to meet the needs of the local LGBT population. Here, I would like to pose a few questions for you, the reader, to reflect on. (1) Does the signposting and local LGBT resource information in your service increase access to IAPT for your local LGBT population, or is it being used to signpost LGBT people because your IAPT service is not meeting their needs? Aside from someone coming to an IAPT appointment wishing to know what the local LGBT resources are, for example a local choir, social event, and coming out support group, if the person has been referred to an IAPT service for help with anxiety, depression, or panic, then what function does the signposting information serve? No doubt it will offer something to demonstrate to commissioners that LGBT inclusion work is being done within the service, but does this work stretch to staff training about the experiences and needs of the local LGBT population? The adaptation to cisgender heteronormative frames of guided self-help (GSH) material? Do the clinicians working in your IAPT service have an awareness and understanding of the impact of minority stress and barriers to accessing mainstream services? Is there adequate provision of high-intensity therapists more commonly required by people who present with gender and sexual differences? (2) Is the signposting and local LGBT resource information based on community engagement, as well as knowledge and understanding of other local services? My own example here is of supervising a very kind, compassionate, and well-meaning practitioner. During a case management supervision, they explained that their recent patient was a transgender person who was experiencing problems with a co-worker intentionally misgendering them in the workplace, calling them by their dead name (the name they were previously known by, prior to gender transition). This had resulted in the person having feelings of gender dysphoria when they were at work, had subsequently been signed off work sick and had started to experience panic attacks when leaving the house. Rather than identifying the situation (problem with the co-worker), the resulting physical symptoms of anxiety (leading to panic attacks), thoughts of passing out if I go into work, the safety behaviour adopted (staying at home), and the resulting emotion (shame), the practitioner had suggested the person speak to their GP about a referral to the Gender Identity service for help with gender dysphoria. I explained to the practitioner that the gender service offered assessment and support for people wanting to transition and did not offer swift access to CBT-based therapy for panic attack management due to problems in the workplace. Also, the person may benefit from speaking to an employment support advisor (part of the IAPT service) who could help them liaise with their firm's human resource officer. We established that the person did not in fact require onward signposting and had been accurately referred to IAPT by their GP. We talked together about how the practitioner had heard the terms gender dysphoria and transgender and had thought this is not what IAPT does! A focus on the person’s gender identity rather

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than the context of the problem at work leading to panic attacks had led to unintended pathologising of the person’s gender identity as the source of the problem requiring therapy. (3) Are you adequately supported as an LGBT champion and are you given time to do active inclusion work? Essentially, anyone taking on the very brave task of attempting to modify systems is going to need time and support.

Common fears: Working with gender and sexual diversity Whilst writing this book, both Liz and I have been involved in various training seminars with NHS trusts and the British Association for Behavioural and Cognitive Psychotherapies (BABCP) aimed at low-intensity continuous professional development (CPD). Our aim here was to support both in-training and qualified practitioners to work inclusively with gender and sexual difference. One of the main themes coming from these sessions was clinician anxiety. Our seminars were online during the COVID-19 pandemic, initially incorporating digital break-out rooms during minigroup tasks to discuss delegates’ hopes and fears of working with gender and sexual difference. Whilst in the break-out rooms, many of the delegates experienced adverse reactions. Our learning here was that it was safer to keep everyone together as a large group in future seminars, letting people approach the topics at their own level of comfort. For those who did feel comfortable engaging in discussion, the main theme was a fear of getting it wrong. Essentially, being afraid of upsetting or offending people was getting in the way of openly asking questions about a patient’s gender and sexual identity. My take here, which in part formed the basis of my own doctoral thesis, is that there is anxiety on both sides of the fence: anxiety from patients who are afraid to disclose their gender and sexual identity due to clinicians’ perceptions, and anxiety from clinicians who fear being negatively perceived as having a lack of knowledge and expertise about different gender and sexual identities. The reality is that no patient or clinician can ever predict how the other will respond, or be without fault, free of making errors, regardless of gender and sexual differences. To be able to perform ‘perfect’ psychological therapy in ‘perfect’ conditions, the clinicians themselves would have to be personally flawless and work in systems that are flawless, with patients who have perfectly fitting problems. It is a practical and human impossibility. So, is it better to make mistakes by trying to include diversity and difference, apologising if we offend or upset than not asking the questions and dismiss important aspects of a person’s experience within the therapeutic space, based on our own anxiety? My personal opinion here is that we have no option but to embrace the potential for making mistakes if we are to truly work inclusively. I will now offer an in-depth case study from my own clinical practice, mostly this was a period of learning and getting it wrong whilst also trying to offer imperfect affirmative practice. The case of David is based on my face-to-face work prior to the COVID-19 pandemic and, whilst fictionalised, is inspired by real events and people. The account is as near to the work as I can ethically relay.

Case study: David Within the GP surgery where I worked at the time, it was very common to experience high nonattendance, or ‘Did Not Attend’ (DNA) rates for initial IAPT assessment appointments. In an attempt to reduce DNA, I had an arrangement with the GP surgery that any spare or cancelled sessions on the day could be filled by ‘walk-ins’. Essentially, if the GPs had someone attend that they thought would be suitable for psychological therapy, they could send me a message via the electronic system and the person could be booked into any available slot on the day. It wasn’t a perfect system but we did manage to reduce the nonattendance rates by around 30% using this approach. This also meant that assessment appointments were more readily available with no waiting time. However, there were high numbers of people who accessed high-intensity therapy following a course of low-intensity intervention, the waiting list for CBT and counselling in the surgery was around 12 months (Box 6.1).

Box 6.1 David is a 29-year-old cisgender gay man who lives alone in a local authority-owned apartment block in an area with high levels of income inequality. Although David has previously reported struggling with depression, this is his first presentation to psychological services. He has attended a GP appointment to request help with managing anxiety, struggling with worsening symptoms of panic attacks that have led to his being off work sick from his job. It has taken David a lot of courage to attend the GP appointment, he is now at a point where he is

becoming socially isolated and has started to have thoughts about not wanting to be here anymore, this has frightened him. David has previously tried antidepressant medication but did not tolerate it and does not want to start taking it again. He has a good relationship with his best friend Kelly as well as with Joan and Irene, a married lesbian couple whom he has had an established close friendship with for several years. Concerned for David, they have encouraged him to seek professional help.



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By chance, David had presented to his GP just before lunchtime and I had a last-minute cancellation straight afterward. The GP came to see me face-to-face and was flustered, it was easier to speak to you rather than trying to explain it in a message. Animated, the GP was struggling to get across the general sense of David’s problem, there was a lot of information given to them and David was incredibly anxious. The GP suspected that the primary problem might be social anxiety but they were mostly concerned with the reported symptoms of depression and thoughts of suicide. The GP did not feel that secondary care services would accept a referral, he doesn’t want medication and I’m a bit stuck as to what to offer him. The local area was challenging to work in and sometimes having a “walk-in” availability could lead to people being sent to me who were in crisis and therefore not always suitable for primary care. However, I had good working relationships with the GPs in this particular surgery and trusted their intuition and judgement. I agreed to see David straight away.

Assessment of risk Whilst waiting in the reception area, David completed the minimum data set (MDS). His scores for depression on the PHQ-9 were 21 out of 27 and had indicated daily thoughts of suicide or self-harm. His scores on the measure of generalised anxiety (GAD-7) were 11 out of 21, as well as scoring 6 out of 8 on the phobia scale, suggesting a high avoidance of social situations for fear of having a panic attack. The first 15 min of our 45-min appointment were spent talking about risk. David was experiencing daily thoughts of feeling that he would be better off dead, but did not wish to die, and did not have any plans or intent to harm himself or end his life, but was experiencing recent verbal threats from the neighbours. These were people he had known for quite a long time and were known locally as drug dealers. He had previously experienced similar verbal slurs from them but was normally able to brush this off, putting it down to the intentional intimidation of the local people to ensure that no one called the police. But this had started to upset David over the past few months, and he was starting to feel afraid of leaving his home. I explained to David that he could report this as a hate crime but he was reluctant to contact the police for two reasons. First, there were few openly gay people that lived within the apartment block and it would be very likely that the drug dealers would realise that it was David who had called the police. Secondly, there was a micro-culture within this particular area where there was a general dislike of the police. The local ‘rule’ was that the only time you should ring the police or bring the police into the local community was if a child had gone missing or there had been a fatality. For David, he felt it was actually far safer for him not to report the verbal abuse. There was also concern about personal neglect. Since being off work due to panic attacks, he had gone from a full-time salary to statutory sick pay. Due to the lack of income, he was not eating properly and he was sitting in the dark with the lights off and the heating on as low as he could bear. These were not intentional acts to harm or punish himself, he was prioritising his rent. David was very worried that he would lose his home. It would later transpire that he had been homeless as a young person and was adamant that he would hold on to his property. I discussed potentially getting David temporary access to a food bank but David expressed a high level of shame around this and felt too anxious to attend.

Initial impressions My initial observations of David during the first assessment session was that he was very visibly experiencing high levels of anxiety and when asking him to focus on his physical symptoms his mind went blank, or would give me vague answers and immediately skip to narrating self-critical thoughts. I was also struggling to slow him down or pause whilst he was relaying vast amounts of historical information and events that were being presented in no particular order. I was beginning to understand why the referring GP had struggled with David during a short physical health consultation, and at times I was feeling overwhelmed myself. Following the lengthy risk assessment and attempts to understand the primary problem David wanted help with, we eventually ran out of time, unable to establish a problem statement or goals for treatment. I offered David another appointment a week later to extend the assessment. The main aim here was to try to understand whether low-intensity intervention was going to be appropriate or whether a further assessment with a high-intensity therapist would better meet his needs. I asked David to complete a timeline and five areas conceptualisation outside of the session (Fig. 6.2), and to think about what he might want to gain from treatment. The rationale here is that David might be less anxious at home and be able to better articulate his needs without the interpersonal pressure.

FIG. 6.2  Out-of-session homework following assessment session one.

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Adjustments to the service policy David did not attend (DNA) his next appointment due to a stomach problem, calling the GP surgery just before the session. I offered David a further appointment, and a few days prior he called into the surgery and handed his completed timeline and five areas conceptualisation to the reception team, asking that this be passed on to me. He then did not attend the rescheduled appointment, again calling the surgery citing stomach problems. This then created a dilemma due to the service operating a common policy within IAPT (and the wider NHS) of ‘two strikes’, interpreted as there being a low likelihood of engagement and typically resulting in discharge from the service. I discussed David’s case with my supervisor, and given our experiences in the local area, David had shown some motivation for engagement by sending in the timeline and five areas, and we agreed that under reasonable adjustments we would write to David offering him a telephone assessment. The rationale here was that he might be less anxious if he had less buildup to the appointment if undertaking this from his home. At the time of the telephone appointment, David's mobile phone was continuously going to voicemail, and after many attempts, I started to record the session again as nonattended and started to arrange his discharge from the service. The surgery receptionist then called the telephone in my room to let me know that David had arrived face-to-face and was waiting for me at the front desk. Although technically he had exceeded the 10-min late attendance policy, I decided to see him.

Session 2: Barriers to engagement (COM-B) David’s self-completed timeline outlined four key periods of his life (Fig. 6.3). He was bullied throughout school and was called queer by the other boys. During his mid-to-late teens when he came out as gay, his parents kicked him out of the family home telling him that his behaviour was disgusting and that he would go to hell. At the age of 19, he met his partner Tom who died in a car collision 2 years ago. Each experience strengthened the belief that there was something wrong with him.

FIG. 6.3  David’s timeline mapping the development of Negative Automatic Thoughts (NATs).

His self-completed five areas (Fig. 6.4) depicted a generalised hot thought about someone criticising and hurting him, followed by what appeared to be core beliefs. He noted a ‘burning feeling’ which he had articulated during his initial assessment but I had not really picked up on at the time. Based on the timeline, five areas conceptualisation and David’s general presentation in the session, my own anxiety was elevated and my mind was more or less already ruling out any hope for low-intensity intervention, leaping towards thoughts as to whether David would need high-intensity CBT, counselling, or longer-term specialist services.



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FIG. 6.4  David’s self-completed five areas model. (Adapted from Greenberger, D., Padesky, C.A., 2015. Mind Over Mood: Change How You Feel by Changing the Way You Think. Guilford Publications.)

I was also aware that David may be experiencing difficulties being in the session with me, his history included a lot of experiences of explicit negative evaluations from others, including more recent homophobic slurs from his neighbours. I opted for a more directive approach to try to help with containing the session, as well as trying to understand any potential barriers to engagement through a ‘right here, right now’ approach, expanding on the five areas conceptualisation (Fig. 6.5).

FIG. 6.5  Expanded ‘right here, right now’ formulation. (Adapted from Greenberger, D., Padesky, C.A., 2015. Mind Over Mood: Change How You Feel by Changing the Way You Think. Guilford Publications.)

Five areas: The right here, right now The expanded five areas conceptualisation was completed within the first 10 min of our 30-min appointment, David and I then started to formulate a problem statement to create a simple but specific narrative to the difficulties that he was experiencing and how the IAPT service might be able to help him (Boxes 6.2 and 6.3).

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Box 6.2 PWP: This thought here David, the one with the star by it, ‘they will criticise and hurt me’, is that the main thought that you get? David: Yes, that’s the main one PWP: Hence the star! David: That’s right, and I also think about …. PWP: [interrupts] and when you get that main thought ‘they will criticise and hurt me’, what happens then? David: I don’t know what you mean. PWP: When you get the thought ‘they will criticise and hurt me’ what do you predict will happen? David: Someone will say something bad to me and that has happened to me, you know, I told you about how it happened to me at school and with my parents, then I think I am disgusting and wrong, and when I was at … PWP: [interrupts] So when you get the thought ‘they will criticise and hurt me’ you fear a consequence? David: I guess so, yeah. Did I do that wrong? PWP: You are doing a great job of explaining this David. When you get the thought ‘they will criticise and hurt me’ what do you notice happening in your physical body? David: I don’t know [body posture leaning backward] PWP: Do you notice symptoms of anxiety in your body right now? David: [pauses] I don’t know, I guess, I just get this tension [clenches his fists] and this weird burning sensation like my blood is on fire. PWP: Do you notice that you are clenching your fists right now? David: [looks surprised and un-clenches his fists] am I? [laughs] PWP: What emotions do you feel when you get the tension and the burning feeling like your blood is on fire? David: I don’t know what you mean, do you mean in my body? [clenches his fists] PWP: I’m not trying to put words in your mouth David, but what we know about emotions and the physical body might suggest that the emotion you feel when you clench your fists and feel burning in your body, would be anger. David: Anger? [pauses] well, yeah, I guess I do feel angry [pause] but I don’t, I don’t like to think of myself as an angry person. PWP: Of course, and I am not trying to suggest you are an angry person, going around punching people. But it would make sense that if you perceive criticism or that people will say hurtful things to you then that might make you feel cross. David: Yeah, it does. It does make me feel cross, I think they will judge me for being gay. PWP: And if you get cross with someone for judging you for being gay, say you REALLY told them off for saying hurtful things to you, what might happen then?

David: They might retaliate. PWP: They might retaliate, that might be the consequence? David: Yes, they might hurt me. PWP: But instead of being angry at someone for criticising and judging you, you turn the anger on yourself, telling yourself you are stupid, disgusting, and worthless. David: Yeah! [long pause—thinking—starting to get upset] I’ve never thought about that before [long pause—tearful]. Yeah, I do speak to myself aggressively, I tell myself I am disgusting and stupid. Then I get the tension, a horrible sick feeling in my stomach, like I need the toilet. PWP: So when you meet someone new, you think they will criticise you and judge you for being gay, this makes you feel angry, you fear that someone will retaliate if you express the anger, that triggers anxiety and gives you these horrible feelings of tension and sickness in your stomach, needing the toilet. David: Yes, it’s just like that. PWP: And then what happens? David: I either avoid meeting people or try to make them laugh. PWP: You make them laugh if you can’t avoid them? David: Yes, I say something funny or sarcastic about myself. PWP: And avoiding them? David: I just don’t turn up [laughs]. PWP: You don’t turn up. That happened with the sessions here, the last couple of times, didn't it? David: Yes, it did [laughs] I’m sorry [looks at the floor]. PWP: There is absolutely no need to apologise. It makes sense that if you fear that I might hold thoughts of criticism or judgement about your sexuality and that makes you angry and you become anxious because you think I might retaliate, this generates feelings of sickness and needing the toilet, then, of course, you would want to avoid me. That makes sense, doesn’t it? David: Yeah, it does [smiling, body posture leaning forward] PWP: And if you experience this with people in your day-today life, then it also makes sense that this will happen here with me, doesn’t it? David: Yes, it does. I had never thought about it like that. PWP: And how do you feel now, sitting here with me? David: I actually feel okay now. PWP: No sickness in your stomach or feeling like you need the toilet? David: No, that’s gone away. PWP: I wonder why that is? David: Well, you seem okay with it.

Box 6.3 Problem statement I think people will judge me because of my sexuality. I get angry, and I’m afraid that I will say something bad and there will be retaliation and they will hurt me. I manage this by blaming myself.

When I meet someone new, I feel sick, my body goes tense, I feel like I need the toilet and I cannot think clearly. I avoid meeting people to stop these feelings.

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I also asked David what would be the worst thing that he had predicted that I might do during the session. His response was not what I expected, but was crucial information. What David did want was some help managing the symptoms of panic and anxiety to help him return to work. What he did not want was to be judged, told he was mentally ill, or wishing to explore painful events from his past (Box 6.4).

Box 6.4 What was the worst thing that you predicted that I might do or say during the appointment?

I was really worried that you would tell me that it was my fault and that I was crazy, and that I would need to talk about my parents.

Complex problem or complex context? The narrative offered by David over the first assessment session was a rapid fire round of events, thoughts, and emotional experiences throughout his lifespan. Each piece of valuable information helped us in terms of thinking about the suitability and efficacy of low-intensity intervention. However, it also blurred the focus of my thinking, my general sense of David’s history and his presenting difficulties was that he would at the very least require high-intensity therapy. There were many factors to consider here. First, his experiences of homophobic slurs from his neighbours led to him not wanting to go out, but up until a few months ago he was established in his home and did not wish to move or to contact the police. He was also presenting with risk factors but did not meet the threshold for community mental health services due to the passive nature of his thoughts and could also draw on protective factors. There was also a consideration here that the waiting time for high-intensity therapy was around 12 months. What would David’s life be like then? Would he lose his job? Would he deteriorate to the point where he was suicidal? If considering high-intensity CBT, why not start with low-intensity CBT around managing the autonomic symptoms of panic? When filtering out the background context, although very relevant to his assessment and treatment planning, we were able to narrow down that his key ‘hot’ thought that was driving the cycle in the here and now (Fig. 6.6). This was a prediction that he would have an anger outburst in a social situation, this triggered the autonomic symptoms of panic and he was managing the feared consequence by isolating himself and avoiding meeting people.

FIG. 6.6  The wider context surrounding David’s case.

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Fine-tuning the problem David explained that the onset of the severity of his symptoms had started around 6 months ago, gradually worsening over the past few months. This followed recent contact with his mother who had been in touch with David after seeing a counsellor through her church. The counsellor suggested that she try to reach out to David and subsequently invited him for dinner. Although somewhat sceptical, David had hoped that this was a sign that his parents were becoming more accepting of his sexuality and were reaching out to reconnect, maybe even apologise. When David arrived at the family home, his dad answered the door and shook David’s hand. As David went inside to greet his mother, he noticed his dad washing his hands in the kitchen sink. This had essentially ripped off a scab that was covering an open wound, David managed to contain his upset throughout the evening, holding back his anger towards his father. David’s mother then asked him if he would consider going to see the counsellor at the church. When David enquired as to why this was being suggested, given his mood was relatively stable, his father boldly interrupted claiming that the counsellor was “ex-gay.” After a short whilst, holding back tears, swallowing his disappointment and noticing a strong rise of anger, David politely excused himself, said his goodbyes and closed the door, including the metaphorical one in his mind. David had previously learned to compartmentalise the rejection he felt from his family at a young age, putting it in a box with only the occasional moments where the lid would come off, mostly mapping the historical episodes of depression. These episodes would normally be short-lived, lasting no more than a week or two. This time the lid had come off and David was struggling to put it back on (Fig. 6.7). The isolation from avoiding anxiety inducing situations was leading to lowered mood, he was worried that he would lose the home he had established, and this had generated thoughts of not wanting to be here anymore, what would be the point of living, then?

FIG. 6.7  Overview of initial assessment for suitability to LICBT.

David’s goals were to be able to manage self-criticism which had been highlighted through his five areas in the right here, right now, but he was also desperate to return to work, this was both a necessary and highly valued activity for David.

Supervision: Fine-tuning the intervention Talking about David’s case in supervision took around 30 min, meaning that I had to arrange additional supervision time for the remaining cases, at a later date. Whilst it is common to hear phrases in low-intensity supervision such as “give it a go,” both my supervisor and team manager at the time were of an era where thorough assessment and evidence-based practice were prioritised over access targets.



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First, we considered the possibility that David’s problem might be in keeping with Social Phobia, and by completing the Social Phobia Inventory-SPIN (Connor et al., 2000) this would mean a straight stepping up to high-intensity CBT under NICE guidance. However, whilst David would likely score over the clinical threshold on the SPIN based on the information he had already provided, he had previously not experienced problems with social functioning, the onset of his symptoms was recent and his primary aim was to return to work as soon as possible. Next, we discussed the rationale and likely efficacy of low-intensity intervention (Fig. 6.8). Initially, cognitive restructuring (CR), as there was a key ‘hot thought’ but this was a prediction about a social context, and whilst not impossible to challenge and test this out, given David’s history, this would likely elicit core beliefs. He also had a lot of evidence to support his belief that people may criticise and judge him for being gay, historically from his family, and perpetuated in the here and now by his neighbours. CR at low intensity had little support for its efficacy and was very likely a poor match to David’s context.

FIG. 6.8  Fine-tuning the suitability of LICBT intervention to David’s problem and context.

We then talked about behavioural activation, attempting to help David with the symptoms of depression, and this was in line with his goals of wanting to return to valued activities such as social contact and work. However, the autonomic symptoms of panic were getting in the way here. No matter how thorough the behavioural diary and balance of routine, necessary, and pleasurable activity were, without addressing the barrier to activation (the autonomic symptoms of panic), we would be setting David up to fail. Finally, we were left with graded exposure, less of a focus on cognitive processes and David could learn techniques to manage his physical symptoms of panic alongside gradual and graded habituation to feared situations, including a phased return to work. Our summary here was that I would talk to David, offering transparency about our rationale for low-­ intensity exposure therapy, with an option to complete the SPIN and step up to high-intensity therapy should we need to. David opted for low-intensity therapy.

Session 3: Selecting materials David was able to see from the exposure and habituation rationale (Fig. 6.9) that his avoidance of situations based on his predictions was maintaining his problem, making immediate sense to him. We discussed the option of either using a guided self-help (GSH) workbook or working in a way that was more individual to David, using a simple diary and grading hierarchy. David had a brief look through the workbook as we were speaking, whilst he understood the link between graded exposure for his problem and the dog phobia vignette in the workbook, wrinkling up his nose and in a mildly sarcastic tone, he said I may write my own. My response here was, what a brilliant idea!

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FIG. 6.9  Maintaining cycle of panic. (Adapted from Clark, D.M., 1986. A cognitive approach to panic. Behav. Res. Therapy 24(4), 461–470.)

We also considered the potential benefits of progressive muscle relaxation, a staple low-intensity intervention used to help people to reverse the physical effects on the body from anxiety, such as muscle tightness, tension headaches, and providing some space in the day to pause and focus on being in touch with the physical body. David was less keen on this and experienced a lot of problems trying to implement it, but he did eventually manage to adopt routine practice of it, albeit with a little help from guided audio recordings.

Guided self-help: Standardisation Selecting self-help material with any patient in an IAPT service can be challenging, there is a lot of it out there freely available in the public domain. Yet, there are varying degrees of quality and accuracy, including popular materials based on CBT, that are written by people who have no formal clinical qualification as either a low-intensity psychological practitioner or CBT therapist. Most of the IAPT services I have worked with either recommend specific workbooks vetted by their clinical team, or use workbooks that they have published themselves. Increasingly, ‘single-strand’ intervention is being adopted with ‘disorder specific protocols’ being encouraged. On one hand, this approach could be useful in attempting to steer practitioners to adopt consistency more broadly, or attempt to curb clinical drift or interventions that are poorly matched to the presenting problem. On the other hand, my opinion here is these are less helpful when working with people who hold differences. Say for instance that David had not told me about his prior history, and his primary problem appeared to be depression rather than anxiety. His goal of wanting to manage self-critical thoughts would likely guide a low-intensity practitioner to suggest either behavioural activation (BA) or cognitive restructuring (CR) as suitable options for intervention. If given David’s primary concerns around self-criticism, I had opted for CR under a single-strand intervention, and this would likely include working through a step-by-step process using a protocol or workbook. In the service I worked in at the time, opting for a workbook would likely lead to ‘unhelpful thoughts; challenging and testing them out’ (Cedar; University of Exeter). Below (Fig. 6.10) is a similar generic case vignette adapted from the Cedar guide, this is then compared with David’s story (Fig. 6.11).



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FIG. 6.10  Typical case vignette from LICBT material. (Adapted from the Cedar Guide: Unhelpful Thoughts Challenging and Testing Them Out. Credit: https://cedar.exeter.ac.uk/media/universityofexeter/schoolofpsychology/cedar/documents/liiapt/Unhelpful_Thoughts.pdf.)

FIG. 6.11  David’s self-initiated case vignette.

Now consider the typical psychoeducational section from the LICBT guides on thinking styles and errors. If you were working with David in your clinic, what would your thoughts be around the suitability of the workbook to David’s context? (Box 6.5).

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Box 6.5 Typical LICBT psychoeducation material After I had written out my thought diary and checked these against the list of common thinking styles in the workbook, I realised that many of them related to thinking errors based

on assumptions about how other people might view me. I discussed these with my low-intensity practitioner who helped me to see that my thoughts were not necessarily facts.

David is an intelligent young man and would quite likely be able to bend and shape his personal story and experiences to fit with the material outlined in Robert’s story. However, given that David has had to bend and shape himself to fit within society for most of his life, will David actually be able to see himself in the material? His thinking is congruent with his actual social experiences, are his thoughts just thoughts and not necessarily facts? It is quite possible that he will have people within his local area who will not hold critical or judgemental views about his sexuality, but how does David trust this? Given his experiences since childhood, how easy will this be to challenge and test his thoughts out? Does a service that offers psychotherapeutic intervention through a cisgender heteronormative lens mean that David can feel reassured that the service is for him and that the practitioner will not hold similar views to those of his family and his neighbours?

Equality of access vs equity of access Does standardisation in services mean that everyone has the same access to the same evidence-based treatment and approach? For people with differences, particularly those with marginalised identities who experience ongoing discrimination and oppression in society that often goes unaddressed in institutions, and organisations (Shin et al., 2017), means that standardisation can lead to locking out people who do not neatly fit with the ‘standard’. The IAPT manual (The National Collaborating Centre for Mental Health, 2021) proposes equitable rather than equal access to psychological therapy. The difference between equity and equality is that we do not treat everyone the same, acknowledging differences and making adjustments as the majority, to include those from the minority. Equitable access means creating systems and processes that allow a ‘leg up’ for people who are on a ‘back foot’ attempting where possible to reduce the barriers for marginalised people so that they can stand the best chance of receiving similar benefits as those with fewer barriers.

Adaptations in guided self-help During the seminars that I have presented around the topic of LGBT inclusion in low-intensity practice, a common question that I am asked is how to adapt therapy for LGBT people. Essentially, people often want a ‘how to’ manual. My response here is one of transparency as to my beliefs about therapy generally, that there is no such thing as “LGBT CBT.” You are either doing CBT well and tailoring it to the individual, or not so well, tailoring the individual to CBT. If you are religiously following a workbook and protocol over the person sitting in front of you, then it is my opinion that you are not doing lowintensity therapy. The role of a low-intensity psychological practitioner is not to walk someone through a guided self-help workbook page by page. The core skill set is having the ability to take the theory and core principles for the evidence base of the intervention and to shape it to fit around the person, not the other way around. My personal way of adapting lowintensity intervention for people, particularly with people who hold differences was to use four basic principles. 1. Be curious about the person and be open to hearing and validating their story. 2. Offer an affirmative stance without assumptions, reflecting on your own personal biases. 3. Keep it simple and co-create with your client. 4. Utilise the person’s strengths and resources and include these in relapse prevention. In my work with David, we used an exposure rationale worksheet outlining the maintaining cycle of avoidance, a graded hierarchy and diary planner, a progressive muscle relaxation instruction sheet, and a meditation audio recording. We incorporated David’s personally written vignette depicting his own story alongside his strengths and resources as part of his relapse prevention plan. David wanted to remind himself of how he had come to this point, should he face problems in the future. Below (Fig. 6.12) is a basic outline of the key components of my sessions when I was working at low intensity with any patient (Box 6.6).

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FIG. 6.12  Key components in an episode of care using LICBT.

Box 6.6 Whilst not specifically aimed at low-intensity therapy, for anyone wishing to engage in further reading around the adaptation of self-help-based CBT and third-wave approaches I can highly recommend The Queer Mental Health Workbook: A Creative

Self-Help Guide Using CBT, CFT and DBT (Dunlop, 2022). Andrew Beck also offers a fascinating insight into cultural adaptations of CBT in Transcultural cognitive behaviour therapy for anxiety and depression: A practical guide (Beck, 2016).

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Deficits vs strengths Incorporating strengths in low-intensity practice is vital. It is common in most therapeutic modalities to be problem focused, which is equally important, obviously, patients do not attend psychological therapy appointments typically because they do not have a problem. However, it is also important to help the person understand the problem and help them to find solutions; sometimes, this is simply a single technique to help someone cope with an ongoing problem. But overly focusing on problems without incorporating the person’s strengths might lead us towards firefighting. What I mean here is that the person talks about multiple issues that are involved in the problem and the tendency for a therapist or practitioner to attempt to be helpful by offering lots of prescriptive suggestions, rather than collaborative, patient-led solutions. Also, if we consider David’s hierarchy of needs (Fig. 6.13) within the context of both deficits and strengths, the deficit in his primary needs could be met through returning to work, and was one of the key factors for David opting for low-intensity intervention, to protect his basic needs, such as safety, shelter, and belonging that had previously protected his resilience and esteem.

FIG. 6.13  Focusing on strengths rather than deficits. (Adapted from Maslow, A., Lewis, K.J., 1987. Maslow's hierarchy of needs. Salenger Incorporated 14(17), 987–990.)

There is also a sad reality here, regardless of intervention or therapeutic modality, in that David has no control over the attitudes, values, and beliefs of other people. It is also likely, given the history of social attitudes, including those of the local drug dealers, that he will continue to experience some form of discrimination and oppression ongoing. However, David does not have the luxury of waiting around for another 100 years until society moves further towards treating each other with more kindness and compassion.

Sessions 4–8: Outcome and ending I worked with David over eight sessions including a follow-up to review his progress after discharge. Whilst the work was not without some difficulty, David worked very hard to achieve his aims. We also worked collaboratively with the GP surgery, David would attend routine follow-ups with the GP, but was also allowed to attend the surgery to sit in the reception area until his anxiety reduced, and was able to repeat this throughout the first 2 weeks. David also contacted his employer to agree to a phased return to the office, where a new co-worker ‘Daniel’ had started working. David talked about Daniel quite a lot during the latter half of his sessions, but this was not explored in any significant detail, as this was beyond the remit of low-intensity therapy and not conducive to the short session appointments and our focus on graded exposure. Yet, my subjective take on David’s focus on Daniel was that the workplace he feared was now somewhere that felt more exciting and interesting. As is often the case, external changes in the person’s life can often steer the course of clinical outcomes, beyond any clinical intervention that we might deliver. Although David reached clinical ‘recovery’, I strongly believe that Daniel offered him something more healing than anything I could offer in my box of low-intensity tools, but LICBT was a key tool in helping him to reach this point. At the final session, David’s scores were PHQ-9: 9. GAD-7: 5, Phobia scale:1/8, and Risk (PHQ-9 question 3: 0/3) and had been sustained for the past two sessions. What was most important from the work that we undertook was the very rapid

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reduction in risk over the initial two sessions of our work together and this was sustained at a brief follow-up a month after discharge. As part of his relapse planning, I offered David the option to refer him to an advocacy worker through a local charity to support him with the verbal abuse he was receiving from the neighbours. David told me that he did not feel he needed this and was feeling more like his old self. I offered to signpost him to a local LGBT community group from our ‘champion’ resource list, to increase his social network, he was not keen and politely declined. When reviewing what David had found the most helpful part of the work from our sessions and what he might wish to document as part of his relapse prevention plan, David recalled our second session, working through the five areas conceptualisation in the right here, right now (Box 6.7).

Box 6.7 What have you found helpful and what will you take away? Understanding what I was doing, and why, was a game changer. I’ve proved I can manage if it happens again and I know how to get myself out of it.

Challenges to the alliance: Therapeutic boundaries The main challenge to the therapeutic relationship was around therapeutic boundaries towards the end of the work. At his discharge appointment at session seven, David asked me if I would accept a ‘friend request’ from him on social media. My immediate reaction to this request, as is the case with any request of this nature, was no. However, rather than jumping immediately to the policy and ethics statements, I would normally give, I paused a little, curious to understand the request. David had been quite distant during his sessions, mostly engaging with me at arm’s length and I was somewhat puzzled by his attempt to engage with me outside of sessions. I approached my response sensitively, and David was able to tell me that whilst he was feeling better and had felt he had made some good progress, he had been told by a colleague at work, in IAPT you never see the same person again, they are always changing staff and he was worried that if he did need support in the future then he would want to make sure that he could see me again (Box 6.8).

Box 6.8 Can I ask why you would want to add me to social media? Just in case you move somewhere else and I need help with my mood.

Whilst David’s request made absolute sense, and it could be tempting to agree to his request, particularly as David had experienced rejection within his relationships previously, regardless of how well intended this action might be, the safety of the patient is always at the forefront of our ethical decision making. I explained to David that I would be unable to engage with him outside of our professional relationship and would not add him to social media, but this was to offer him the same protection I would offer all of my patients. Whilst disappointed, he understood and accepted this.

Reflecting on the work with David During each of the CPD training and university teaching sessions that I have delivered based on David’s case, I am typically asked, ‘would you have done anything differently?’ As is common in the field of counselling and psychotherapy, I can look back through a perfectionistic lens and beat myself up about everything that I could have done better. Less interruption and direction, more pauses and silence, better Socratic questioning, more focus on the specific primary problem during sessions, more inclusion of the person’s own voice, and better adaptation of the materials. Of course, there is always room for learning and critique, and this is an essential part of the ongoing process of development as a psychological practitioner or therapist. There are two main questions I ask myself when reflecting back on David’s case. (1) Was the work successful? (2) Did I offer good, person-centred care?

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Was it successful? If I base this solely on the outcome measures and David achieving his goal of returning to work as a benchmark of success, then I guess the answer here would be yes. However, I am under absolutely no illusion that eight low-intensity sessions will have resolved David’s tendency for recurrent depressive episodes and the potential for a flare-up of anxiety in different social contexts. So was the work simply a sticking plaster? Given his history and experiences, supporting the process of longer-term resolve and adaptive emotional capacity would likely be long-term work, which is neither the aim nor claim of low-intensity intervention, I would say yes, this was a temporary measure to help the scab reform over an old wound. However, given the demonstrated changes in David’s life, returning to work, and having money to support the maintenance of his home that supported his esteem, my summary here would be that the work was successful for where David was at, at least in the short term. Did I offer good, person-centred care? This is more complicated to think about. Despite there being an endless number of things I might have done differently given foresight prior to the work, there is also David’s consent and systemic processes to consider. First, I think about how I might work with David now if he had initially presented to one of the few specialist NHS services offering longer-term work. During my initial assessment phase, I would likely ask David about his early childhood, and the way his parents would respond to him if he needed help, or had hurt himself prior to the age of six years old. I would be curious about the messages that he heard from his peers through childhood and his early adolescence that he might have internalised, and the ways he might have learned to protect himself during interpersonal conflict. I would also directly ask him about his early sexual experiences and sense of sexual identity as he matured through puberty, as well as his experience of sex and sexuality in the here and now. I would also want to gain a general sense of his patterns in approaching interpersonal relationships, and how he experiences separation and loss. Given that David did not wish to talk about the relationship with his parents and his main aim for therapy was the management of his symptoms of panic, my questions here would be, is David in a position of readiness for deep exploratory work? Would I have David’s consent to do that work? Based on his overall presentation and assessment of risk, it would be unlikely that he would be accepted to specialist NHS services unless he had failed to recover through numerous rounds of low- and high-intensity interventions in an IAPT service first, at least under a progressive model of stepped care. An alternative solution here might have been to signpost David to a primary care service specifically set up to work with people from the LGBT community. The simple fact was that in the area where David lived, there was simply no such service. What about private options? Let’s say for arguments sake that David had a higher income level or health insurance and could financially support himself through private therapy. Here, he would have less restriction on session numbers (depending on whether funded by insurance), the flexibility and choice of modality (depending on the insurer), and be able to choose his own LGBT affirming therapist (provided he understood how to vet the claims and accreditation of the therapist), but he could avoid lengthy waiting lists. It is not uncommon to see patients for up to 3 years in longer-term psychodynamic therapy, particularly if someone is accessing this privately. Whilst David does not currently wish to talk about his parents, we would have the time to build up our relationship, foster trust and stability to be able to safely explore the rage and betrayal he might feel towards his parents, currently directed towards himself. But again, do I have informed consent? The reality here being that David was not in a place where he felt ready to consent to deeper work focused on his past. He did not have the financial means to engage in private therapy, nor did he wish to wait to access a high tier therapy or service. Essentially, neither of us could reliably predict a good outcome or guarantee any long-term effects from low-intensity treatment, but my assessment and intervention were based on the targeted treatment of panic attack symptoms within the context of David’s life and were done transparently, including David’s choice and consent to the work. The caveat here however was that had David wished to access a higher tier of therapy afterward, once the relationship was established and his fears of therapy had subsided, he would not have been eligible for treatment on the NHS given that his outcome measures were scoring underneath the clinical threshold for depression, anxiety, and panic at the end of the low-intensity intervention. By no means had these symptoms entirely gone, but were currently managed. This is by no means an ideal model of care, the conditions and systems are dependent on available resources and the processes are there to ensure the most throughput for the least cost for the general population. I am not attempting to justify the use of low-intensity intervention as a way of plugging a hole stemming from wider systemic problems, or suggesting that low-intensity intervention can replace the important reparative work of counselling and relational psychotherapy. The bottom line is that we worked with what we had available to us within the configuration of NHS-commissioned mental health services in the local area at the time, and David learned to do two things, (1) to manage his symptoms of panic, and (2) establish an alliance with someone who he had predicted would criticise, judge and shame him. So, did I offer good person-centred care? My hope here is that it was good enough.



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Summary and reflective task There are many factors that can impact the journey to the therapy room for people with gender and sexual difference and it is vital that healthcare workers are informed about potential barriers to accessing health care that may be less explicit and perpetuated by the processes and pressures within systems. Working affirmatively is something that any clinician can do provided that they are open to reflecting on their own personal beliefs, and biases, and having a willingness to hear, value, and understand the other. Essentially, empathy and the therapeutic alliance are key here. Collaborative problem formulation, critical self-help material selection, a flexible approach, and including strengths and resources are also vital when approaching the more technical elements of low-intensity intervention. Whilst creativity and adaption are emphasised, this also has to be based on the core principles of the evidence base for intervention. For example, the change method principles for LICBT; grading and habituation in exposure techniques, balancing valued activity and countering behavioural avoidance in behavioural activation. How this is delivered and what is used to deliver it are the main areas where flexible and adaptive creativity of low-intensity intervention can flourish. However, taking on an activist role within systems that are pressured by ingrained policies and procedures, supported by outcome data based on the statistical norm can be tough and challenging work. There needs to be support and time allocated in order to embrace community engagement and linkage work with local organisations and groups to inform and educate services about the needs of all people in their local population, including those who hold minoritised identities. Take a moment to reflect again on your answers to the earlier questions. Are your thoughts the same, or different? What actions might you take to support yourself and your local LGBT community in your future work? 1. Do you practise with reflection on your own biases, beliefs, and values? 2. Is an awareness of your biases enough to make your healthcare service accessible and are you and your service actively inclusive? 3. Does your healthcare service engage in outreach within your local communities, integrated within other services, and offer linkage to a range of access opportunities such as digital? 4. Do you actively seek to consider the history of those whose journey to therapy may include additional barriers to engagement?

Next steps to active inclusive practice Reflective questions for individual clinical practice 1. What are my hopes and fears around working inclusively with gender and sexual diversity? 2. What biases might I bring to a treatment session that could impact patient engagement and outcomes? 3. How might my fears and biases get in the way of my hopes for inclusive practice?

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King, M., Semlyen, J., Killaspy, H., Nazareth, I., Osborn, D., 2007. A Systematic Review of Research on Counselling and Psychotherapy for Lesbian, Gay, Bisexual & Transgender People. British Association for Counselling and Psychotherapy. Le, T.P., Bradshaw, B.T., Wang, M.Q., Boekeloo, B.O., 2021. Discomfort in LGBT community and psychological well-being for LGBT Asian Americans: the moderating role of racial/ethnic identity importance. Asian Am. J. Psychol. 1 (1), 59–73. Lea, J., Jones, R., Huws, J.C., 2010. Gay psychologist and gay clients: exploring therapist disclosure of sexuality in the therapeutic closet. Psychol. Sex. Rev. 1 (1), 59–73. Linehan, M., 2014. DBT? Skills Training Manual. Guilford Publications. Lingiardi, V., McWilliams, N. (Eds.), 2017. Psychodynamic Diagnostic Manual: PDM-2. Guilford Publications. Lloyd, C.E., Rimes, K.A., Hambrook, D.G., 2021. 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Meyer, I.H., 2003. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol. Bull. 129 (5), 674–697. Moller, N.P., Ryans, G., Rollings, J., Barkham, M., 2019. The 2018 UK NHS Digital annual report on the Improving Access to Psychological Therapies programme: a brief commentary. BMC Psychiatry 19 (1), 252. Nadal, K.L., 2019. A decade of microaggression research and LGBTQ communities: an introduction to the special issue. J. Homosex. 66 (10), 1309–1316. Nadal, K.L., Scharrón-del Río, M.R. (Eds.), 2021. Queer Psychology: Intersectional Perspectives. Springer Nature. NHS England, 2019. NHS Mental Health Implementation Plan 2019/20–2023/24. Online. Available from: https://www.longtermplan.nhs.uk/wp-content/ uploads/2019/07/nhs-mental-health-implementation-plan-2019-20-2023-24.pdf. Office for National Statistics, 2017. Depression in the UK. Online. 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Chapter 7

Psychological practitioner wellbeing Elizabeth Ruth University of Bradford, Bradford, United Kingdom

I think the working conditions for so many people aren’t great and they focus on when they’re getting out so that they can stay well now. Tom Fisher (personal communication)

Why wellbeing? Why does wellbeing keep coming onto the agenda? We talk about low-intensity practitioner wellbeing nearly every time we talk about low-intensity practitioners. The unresolved questions are why don’t people stay in low-intensity jobs, and why aren’t they thriving in those jobs? When difficulties arise, it is too easy to blame the individual, to accuse them of a lack of resilience or coping, to blame retention issues on career ambition rather than the fact that too many low-intensity practitioner posts are unsafe and underrewarded. In this chapter, I draw on my observations from my time in various clinical, supervisory, and educational roles in IAPT and other settings where low-intensity interventions are delivered, to highlight what I think are some of the key structural issues that affect practitioner wellbeing. We know that there is a direct link between practitioner wellbeing and the quality of the service that we can provide, as well as a direct effect on retention in low-intensity roles.

Mapping the problems I arranged my thoughts into a mind map (Fig. 7.1), and I will use this chapter to expand on this image. To supplement that, I am going to draw on the responses to a study of low-intensity practitioner wellbeing that James carried out in 2019 in conjunction with NHS and third sector IAPT services in the Yorkshire and Humber region of England. You will find quotes from respondents to that study scattered throughout this chapter. So, without further ado, this is my current understanding of the picture that we’re in. Once I have explained this image in some detail, I will talk about some potential solutions that might encourage some change in the systems that this image describes.

Care in High Volume. https://doi.org/10.1016/B978-0-323-88492-1.00007-5 Copyright © 2023 Elsevier Inc. All rights reserved.

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FIG. 7.1  A mind map that captures some factors which can contribute to practitioner burnout and retention problems in the IAPT programme. (Credit: Original image.)

High-volume, low-intensity work We are low-intensity practitioners employed to provide high-volume, low-intensity psychological care to people with common mental health problems. This describes the work of Psychological Wellbeing Practitioners in Improving Access to Psychological Therapy (IAPT) services, but also is expanding to describe the work of Educational Wellbeing Practitioners, Children and Young People Wellbeing Practitioners, and Mental Health Wellbeing Practitioners. I say a little bit more about each of these roles in my chapter on professional identity. The bulk of the development of this approach has been carried out within the IAPT programme. I will emphasise again that IAPT is not a homogeneous programme. There are examples of teams where low-intensity practitioners do thrive in their role. Unfortunately, these teams with excellent leadership, where the low-intensity practitioners are valued, rewarded, and supported, are not common enough to prevent a national problem with staff turnover and burnout which seems likely to pose an existential threat to the programme if it isn’t resolved. IAPT is an exceptionally target-driven service, and other chapters in this book have explored how that target-driven culture affects some aspects of our working life. For this chapter, we will just acknowledge and hold onto that idea that this is the context for what follows. Several staff surveys over the years have indicated that there are nation-wide problems with how low-intensity roles are implemented and supported. This impacts on staff wellbeing and retention. A survey is one thing, when you are struggling at work, hearing about the same struggles directly from a practitioner who works a couple of hundred miles away is another.



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One of the benefits of our working life incorporating more online meetings over the recent years has been the opportunity to meet and share experience and ideas with practitioners who do not work in our small local area. This means that it is easier to get a sense of what working life is like for practitioners around the country, and if the problems that we have encountered in our ‘home’ team are unique to us or more widespread. Information is power, and this is an opportunity for the workforce to gain information that can inform their expectations, decisions, and relationship with their teams.

Recognition, reward, and respect Moving on to the next box in my chart: What I keep hearing is a repeating theme of the role itself still—even after all of this time—not being recognised. That the rewards for doing the job don’t match up to the good that the role is doing. Practitioners themselves and the interventions that we can offer don’t always receive respect from other psychological and healthcare professionals. Again, this isn’t universal. There are some teams where the professions work together with great communication and mutual respect; there is appreciation for what each therapeutic modality can offer to the overall aims of the team. Unfortunately, teams with hierarchical and bunkered cultures are also out there, and those cultures can have an adverse effect on the practitioners within them (Fig. 7.2).

FIG. 7.2  An excerpt from a mind map that captures some factors which can contribute to practitioner burnout and retention problems in the IAPT programme. (Credit: Original image.)

I worked in my local IAPT team for 10 years. The majority of that time was spent on site, in GP practice buildings, working in collaboration with GPs to provide a psychological service to their patients. Even as I left the service after a decade, I was still having to describe to GPs who I worked alongside what it was I did and who I was as a practitioner. A couple of weeks ago I ran into some senior social workers in our office who had never heard of IAPT. The fact that there can be a multimillion pound investment in psychological provision that is universally accessible to all registered primary care patients, and there be health and social care professionals who haven’t heard of it for nearly 15 years is quite a problem.

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What we do as low-intensity psychological practitioners is not universally understood or recognised. Even within the teams that employ us, we can sometimes feel like we’re at the bottom of the hierarchy of approaches to psychological care, our potential and contribution barely recognised, and often unrewarded. Again, I will keep repeating this because the most vocal critics of this chapter will be the fortunate practitioners who can say ‘it’s not like that in my team!’, I am not describing a universal experience, just a far too common one. There are some good examples of progression, recognition, and reward being available to low-intensity practitioners. The last year (2021/22) has seen the implementation of senior clinical leadership and management roles for low-intensity practitioners in at least two teams, and more representation by low-intensity practitioners at academic conferences.

Comparative deprivation I put the words ‘comparative deprivation’ into my chart in between ‘recognition reward and respect’ and ‘complex work’. There is some history to the choice of those words. In 2021, I chaired a discussion panel at the EABCP conference in Belfast. Panel members were Liz Kell, a former Graduate Mental Health Worker and current academic and teacher at the University of Central Lancashire; Marie Boardman, a lead PWP from a large IAPT service in the English midlands, Allán Laville, a former PWP and now Dean of Diversity and Inclusion at the University of Reading, and Orla McDevitt-Petrovic who has had a leading role in implementing low-intensity practitioner training at Ulster University in Northern Ireland.

Abstract for famine and plenty, Panel Debate 1 EABCP 2021 Belfast/hybrid The first dedicated low-intensity practitioner roles were introduced in England in 2004. Seventeen years later, there has been substantial growth in the workforce: 2461 low-intensity therapists were recorded in the 2015 IAPT workforce census. There is every indication that this number has increased significantly in the last 6  years with the strategic emphasis in the NHS on parity of esteem between physical and mental health care, and the government commitments to continue to improve access to evidence-based psychological therapies. There have been developments in children and young people (CYP) health care, and education-based roles and practitioners have increasing opportunities to specialise their practice in areas of interest like integration with physical healthcare and perinatal services. Despite this, there is no clear career development within low-intensity approaches. Staff wellbeing at low intensity is consistently reported to be neglected, and there are significant problems with staff retention. The PWP Retention Report (2020) demonstrated that most low-intensity practitioners leave the role to pursue further clinical training in CBT or Clinical Psychology after only a short amount of time in the PWP role, and this is also reflected in the limited diversity in the low-intensity workforce which is dominated by young white female psychology graduates. There is growing international interest in CBT-informed low-intensity therapies. For example, in 2013, the Northern Ireland Mental Health Services Threshold Criteria acknowledged low-intensity therapists working at stepped care levels one and two are crucial

for the e­ stablishment of an effective stepped care a­ pproach to psychological therapy provision in the province. Although there is support for the acceptability and effectiveness of the PWP in settings around the globe, it can be a challenge to secure funding for training, and for qualified roles when training is completed; this in direct contrast to a relative affluence of low-intensity therapy provision and job opportunities in England. The IAPT programme in England has provided CBT-informed Low Intensity Psychological Therapies within an environment in which the modality can be defined, and where practitioners can begin to form a sense of professional identity. Despite this, the low-intensity professional group can feel a sense of deprivation compared with the professionals who they work alongside. This deprivation can be in terms of the quality of clinical supervision, CPD opportunities, as well as other aspects of health and safety, reward and recognition, and value of the role. There is an opportunity to recognise low-intensity therapist roles as a core profession. This would provide the same responsibilities, recognition and accountability, and career and development opportunities, as other professions. It also seems essential to provide more routes into training and practice, in order to attract practitioners who will experience this as an aspirational and satisfying profession. As the low-intensity role is adopted in new clinical and international settings the panel will consider several aspects of, and perspectives towards, the retention and development of low-intensity practitioners and the comparative deprivation of the low-intensity workforce compared with the other ­psychological professions.

We highlighted the idea of ‘comparative deprivation’ because quite often there can be a sense that the work that lowintensity practitioners are providing; the value it holds and the good it does, do not receive the same recognition and respect as the other modalities that we work alongside. That can show itself in things like pay inequalities. It can show itself in things like access to high-quality supervision, which is protected for counsellors and CBT therapists but can be a lottery for lowintensity practitioners. Even something as intangible as the regard that you’re held in, the social status that your professional

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role affords, can be lacking in comparison to the professionals who we work alongside. I have heard examples of psychological professionals who hear our job title and respond ‘oh, one of those, you do that low level work …’ with the (incorrect and misinformed) implication that our contribution to our teams and what we offer to our patients is ‘low’ worth. We do not see this happening to the other psychological professions, despite some intra-approach rivalries and disagreements. I worked extremely hard to get this position. However, it all seems to be a numbers game: recovery rates, how many contacts we see etc. It’s quantity over quality and this is NOT the reason why I wanted to work in mental health! PWP (2019)

I feel undervalued which has led me to consider leaving. I’m undecided as to what else I would do so I have stayed so far. PWP (2019)

Complex work This then takes us to the third heading box in my flow chart because alongside all of this, we’re often doing quite complex clinical work; as well as navigating workdays that involve the skillful juggling of numerous organisational tasks and clinical responsibilities (Fig. 7.3).

FIG. 7.3  An excerpt from a mind map that captures some factors which can contribute to practitioner burnout and retention problems in the IAPT programme. (Credit: Original image.)

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In many areas, low-intensity practitioners are a first point of contact with psychological care services. Low-intensity practitioners are exceptionally good at here-and-now problem-focused assessment and have to adapt how they work to engage with people with every identity and background that you can imagine. They do this in an expertly condensed way, working within that target-driven culture, which means that every second spent with a patient has to be used to good effect. The work that low-intensity psychological practitioners do is excellent; small pieces of work that make a large, sometimes life-changing difference. There is no arguing that for some practitioners, depending on their length in the role, how they were trained, the style of practice that they have developed (see my chapter on training and competency for more about that), how they are supervised, and the team culture that they are within, might find the work boring or repetitive.

I regularly feel a tension in not being able to offer what I feel is clinically judged to be the most appropriate service/therapy for an individual. PWP (2019)

The encounters with hundreds, if not thousands, of people that this work offers could be endlessly interesting. No two encounters are alike; each person requires a different sort of thinking and presents different problems that we support them to navigate. For some people, the interest in personalities and the endless variety of problem-solving challenges will be enough to keep this work fresh. For many people though, the high-volume work will wear after a whilst. Some people adopt a more predictable, manualised approach as a way to manage the interpersonal demands of work with so many people. Compassion fatigue, burnout, and vicarious trauma are real risks, and there is more about that later in this chapter. Some people are offered opportunities to reduce the number of hours that they spend with patients and take up leadership roles or service development opportunities (an example of that in my chapter on long-term conditions work), for some, that can keep things fresh enough to make the role sustainable. For the highly capable people in this profession, there is going to be a desire for intellectual stimulation and that can make the thought of adopting new techniques and strategies to enable work with more complex problems appealing.

Not a guru What comes to mind often is the meme from Jurassic Park. You know the one. There’s that dark haired mathematician played by Jeoff Golblum, he is lounging back saying ‘just because you can, it doesn’t mean that you should’. There are increasing demands for low-intensity practitioners to work with trauma, to work with social anxiety disorder, and health anxiety and long-standing obsessive-compulsive disorder (OCD). These anxiety disorders can’t be properly assessed quickly (although they can quite often be identified within the usual problem-focused assessment offered by a low-intensity practitioner), or readily formulated in the simple models that are suited to the time limitations of low-intensity work. For some practitioners, there’s some appeal in more complex work that may receive better recognition and that can offer a new challenge. I don’t want to say that work with more complex problems offers more bragging rights, but there is an implication of something like that; a practitioner who can work competently with complex and entrenched problems can sometimes accrue a quasi-mystical or guru-ish reputation.

Normalising Step 2.5 Other benefits aside, taking on work with complex presenting problems is an opportunity to learn something new. But unfortunately, what we’ve seen that leading to is a normalisation and drift from safe high-volume work with simple depression and anxiety into kind of grey area, sometimes colloquially known as Step 2 and a half, with reference to the Stepped Care model (see Chapter 1), where to work effectively with the patients that you’re being asked to see, you’re having to ­essentially make it up as you go along because there is no evidence for this grey area working. Practitioners have to guess which principles they can safely adopt from other approaches and theoretical models that will be safe to apply in a short and structured piece of work.

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I don’t feel like I am able to deliver the best I can and then feel huge guilt about a person’s IAPT experience if they haven’t recovered. I leave work completely exhausted and feel like I’m not having or enjoying my own life because I’m so tired. PWP (2019)

Clinical drift I hear about low-intensity practitioners offering dialectical behavioural therapy without any additional training because they have been given a worksheet or a website to read by their supervisor in answer to the high volume of patients with self-harming and suicidal behaviours who are referred to the service. There are examples of patchwork interventions that bring together strategies from four or five different approaches into one piece of work, without any proper grounding in the original approaches and theories that underpin these techniques. The short-term, timelimited, structured nature of low-intensity psychological work doesn’t hold this type of patchwork comfortably or safely. As a patient, I would not want to be seen by a practitioner who was ‘having a go’ at working with my problems if they were not appropriately qualified and supervised to do so, but that is what sometimes happens in response to service demands.

Supervision and reflection The complexity of the work—whether that’s run-of-the-mill, ‘we’re assessing lots of people and it’s gonna get tricky sometimes’ or if it is, ‘the service requires me to work with people who are not going to benefit from low intensity interventions because seeing people quickly is more important than matching them to the right level of care’—leaves very little time to reflect. A colleague described that they had booked a break in their clinic to write their notes and catch up with the day but had to make safeguarding calls in that time and then had to work beyond their contracted hours to catch up on the necessary tasks for the day. So low-intensity practitioners are left with no thinking time, which means that there is no learning time. In Chapter 3 of this book, I described how the reflective practitioner is the safest and most effective practitioner. You can only develop that style of practice if there are pauses in the day. To add to this, practitioners will often find that their supervisors are in the same boat; that they are trying to catch up with what they are expected to do all the time. So, there’s very little room for truly restorative supervision in a typical lowintensity working week.

The demands on the PWP role are often unrecognised and as a workforce we rely on informal peer support too much. This often then means that issues are not raised appropriately. Therefore, I recognise my own responsibility in raising concerns when the role conflicts with my ethical or personal values in order to see any change. PWP (2019)

I considered leaving the role due to burnout and being left to deal with complex cases without sufficient training or clinical skills support. All the supervision I receive is to meet the needs of the service and patients but not my emotional needs. PWP (2019)

Target driven Here, if we were looking at the mind map from the beginning of this chapter, we would jump to the left hand side. All of this ties in, of course, to the target-driven nature of the IAPT programme. I’ve recognised how that impacts on the lowintensity working day and time management. Recovery and access targets in particular can intersect with complex clinical work to create a high-pressured environment that keeps the practitioner is a kind of survival mode that is not conducive to the practice of empathy or to reflective practice (Fig. 7.4).

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FIG. 7.4  An excerpt from a mind map that captures some factors which can contribute to practitioner burnout and retention problems in the IAPT programme. (Credit: Original image.)

A practitioner who is working in survival mode does not feel safe, they are not able to do their best thinking, and their creativity is impaired. People who are in a chronic state of stress become less effective problem-solvers, and effective problem-solving is the defining characteristic of a competent low-intensity practitioner.

Micromanagement The target-driven culture that Psychological Wellbeing Practitioners work in doesn’t just affect practitioners. Service leaders and managers are just as likely to be operating in a state of tension and worry as they carry the burden of meeting targets under the threat of penalties for their team. I was lucky to enter IAPT at a time when the PWPs in my team were given targets to achieve, but were largely left alone to meet those targets in the way that best suited their working style. Although this came with additional responsibilities to manage waiting lists and build relationships with Primary Care teams, it meant that I had some power in my working life and could design a working day that suited my working style. I remember one regional meeting vividly where I described our supervision arrangements and the flexibility that I had to offer longer appointments for interpreter sessions and do some community outreach. Another Senior PWP at the meeting turned pale and exclaimed ‘but what about your contacts?’ I achieved my required clinical hours and outcomes without feeling the pressure of a numerical target over my head and in a way that didn’t burn me out physically. There were still challenges, things weren’t perfect, but in light of the accounts that are shared with me by practitioners in recent years, I worked in a heyday. There are increasing accounts of services where practitioners do not control their own diary and are required to overbook their clinics in case some patients do not attend their appointments, where longer sessions to accommodate the requirements of patients with protected characteristics like different learning abilities or language support needs are not accommodated. This corresponds with rising unhappiness and stress in the workforce.

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There isn’t really a way to deal with it as it is a system and service problem with being so target driven. PWP (2019)

It’s difficult not to use other skills when the patient clearly needs them eg. using DBT experience and skills to help patients to manage self-harm. PWP (2019)

Progression frustration The working culture that I have described doesn’t necessarily lend itself to longevity in a job role. Lots of people seek options for progression towards either further clinical training or formal leadership roles that would offer a reduction in the number of clinical sessions that you are required to offer and—in theory—more power to affect the working environment, for yourself and your team. I have written about professional identity and career progression in some depth in my chapter on professional identity (Chapter 11), I won’t repeat that chapter here. I will just note that some services and trusts are brilliant at recognising the transferable skills that PWP’s develop very quickly, and there are opportunities for progression within an organisation. In other teams, there is a hard and fast rule about having a ‘core profession’ before you can apply for jobs above a certain pay band; this is a status not granted to low-intensity practitioners. So you have a staff group who are more than capable of filling leadership and management roles, but they are not even allowed to apply for them in some areas. In the teams that do support low-intensity practitioners to progress to leadership and senior management, we have evidence that the learning and experience from this role creates some outstanding leaders with strong interpersonal, strategic, and organisational abilities. Teams that receive funding from the national IAPT programme to deliver low-intensity interventions in a stepped care system are not currently required to plan and deliver career progression opportunities for their practitioners. Many teams are working on this in recognition of the potential within their staff group, but this creates a lottery where we need a national strategy to enable those practitioners who want to retain the low-intensity practitioner professional identity to achieve their career potential. This can only strengthen the workforce and the IAPT programme. Low-intensity practitioners in leadership roles can use their insight into the realities of the role to make a difference to frontline working life and create opportunities to develop special interests that will improve the quality of what a team can offer to their communities. All of that can be frustrated by that target-driven culture where everything else falls by the wayside in deference to those numbers.

Consequences This picture so far means that we are now in the place to acknowledge the risk of burnout, compassion fatigue, and vicarious trauma in low-intensity practice. In my flowchart, I have proposed that the target-driven culture, the lack of recognition, reward and respect that is offered to practitioners, and the high-volume complex clinical work that they are required to navigate without appropriate training or supervision, all create an environment that increases the risk of burnout. The experience of comparative deprivation might also be a factor in some teams. There is a tendency to attribute burnout to the individual rather than the system, without acknowledging the interaction of the two. Before we dig into this topic, I want to be clear that burnout is an occupational health matter. Practitioners who are affected in this way by their work are too often blamed for the difficulties that they experience. It is not an ­individual’s coping strategies that make a difference there. OK, I’ll admit that statement is too general and sweeping to be useful. Of course, we have got a personal responsibility for our health, but actually, burnout is an occupational health issue. There is only so much that good self-care routines can do for you in the face of pressures like those faced by PWPs and other healthcare workers. In this context, I think we can see where some of these difficulties might come from. In 2017, The British Psychological Society published the data from The New Savoy Partnership’s staff wellbeing survey. Out of 1227 psychological professionals working in the NHS, 48% reported experiencing depression as a result of their work. Target pressures, a culture of fear, inadequate supervision, and poor career progression opportunity are the main themes contributing to this. The picture of poor wellbeing for psychological

practitioners had increased from 40% in 2014 to 46% in 2015. In terms of the IAPT workforce specifically, Westwood et  al. (2017) published the findings of their 2017 survey of 201 IAPT workers and found burnout rates of 68.6% in the low-intensity workforce, compared with 50% in high-intensity modalities. The main predictors of burnout for low-intensity practitioners were found to be workload related.

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I want to pause and acknowledge something important here. In this chapter, we talk specifically about the risk of vicarious trauma, compassion fatigue, and burnout in Low-intensity practice. I can imagine a general nurse who’s been on a COVID-19 ward for the last 2 years, or a medical general practitioner (GP) from one of our local GP practices reading this chapter and scoffing ‘they don’t know they’re born, you think you lot have got it tough?’ That would be a reasonable reaction; we know that people who work in caring professions across health and social care, not just in lowintensity practice, are far more vulnerable to common mental health disorders than the general population of England. All care providers face many of the same work-related stress as low-intensity practitioners. In many ways, psychological professionals have more protection than other health and social care staff as no psychological professional can practice in an IAPT service without mandatory supervision for several hours a month. This chapter is not intended to be a pity party or a misery competition. We do need to talk about the psychological and health risks involved in the IAPT implementation of low-intensity psychological care because it is so often dismissed, swept under the rug with a response that lays the blame for difficulty exclusively on the practitioner, without acknowledging any of the other contributing factors. We want to recognise lowintensity practitioners specifically because that isn’t happening anywhere else. This should not be seen as a dismissal of the challenges faced by other professions but as an account of our own experience and thoughts on this subject. The first time I heard about vicarious trauma I was just over 1 year qualified as a PWP. I recognised that I was struggling and, thanks to my many assessment appointments with people who had symptoms of PTSD, I suspected that I was having a trauma response. In true low-intensity practitioner style, I completed an IES-R (the questionnaire used in IAPT teams in 2011 to screen for possible PTSD) and scored above the cutoff number for possible PTSD. It wasn’t a surprise; I had experienced a few adverse events in the couple of years before that, including some very frightening and overwhelming appointments in my isolated low-intensity clinics in GP practices around the city. My symptoms included frequent nightmares, as if my mind was living some of the stories that patients had shared with me in their sessions. I felt increasingly unsafe when I left my house. I felt isolated, despite having a good circle of friends and someone to go home to. I was physically and emotionally exhausted, flat in mood. My usually cheerful demeanour had changed, I had become cynical and irritable, at work and at home. I was what can best be described as hard-hearted towards my patients, unable to offer my usual empathy and care, although I could still go through the steps of a low-intensity intervention without error. I had received frequent positive feedback from my patients, but I lived with a belief that I was bad at my job, that my team had made a mistake when they hired me. Like a good PWP, I went looking for some self-help material as soon as I recognised that I had got a problem. I found Overcoming Trauma by Claudia Herbert and Ann Wetmore. The authors of that book had a whole chapter called ‘Issues for Professionals and Carers: Vicarious Traumatisation’. It was the first time that I had come across the phrase ‘vicarious traumatisation’; that chapter described everything that I was experiencing and made me realise that there had been a significant and dangerous gap in my training.

What are vicarious trauma, compassion fatigue, and burnout? The language used to describe these experiences is sometimes confused. Some of the concepts and words are used interchangeably when they should be distinct and specific, and sometimes pedantic distinctions are made that get in the way of shared understanding. There don’t appear to be universally accepted definitions for these terms, so instead of presenting a literature review and discussion, I will simply explain what I mean when I use these words and ask for your indulgence if I don’t use the language that you’re used to.

Trauma Some of the negative impact of caring work comes when we have contact with ‘trauma material’. That is when we hear accounts of traumatic experiences and encounter negative psychological (including emotional, cognitive, behavioural, and physical) after-effects of the traumatic experiences that our patients have endured. There are various schools of thought and ways of defining what ‘trauma’ is. For the purpose of this chapter, I will use ‘trauma’ to describe a frightening event or circumstances, like a car crash or ongoing domestic abuse, discrimination or political persecution, that falls outside what the patient thinks of as the normal events of daily life. I won’t touch on developmental or attachment-based trauma as that is far beyond the scope of this book. When the patient has experienced trauma and there are unresolved, persistent memories, or thoughts and feelings about it, psychological work can be more demanding for both the patient and practitioner. This is true whether or not the trauma is the focus of the work they are doing together and can be true even when the trauma is never mentioned or described.



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I am not saying that low-intensity practitioners shouldn’t work with someone who has experienced a traumatic event. The reality is that most people have experienced trauma of some type during their lives, if that was an exclusion criteria we wouldn’t work with anyone. Where things get tricky is if the trauma is not resolved and is the focus of the work; low-­ intensity practitioners are not given the time to do that work well and safely. The training and, more importantly, the supervision required for work with trauma are also outside the scope of our role and competencies. Another element in a helpful definition of trauma acknowledges the ability to recover, develop, and adapt after a traumatic experience. People experience terrible and frightening, disempowering events in their lives but often we heal and grow around or past it. A traumatic experience doesn’t define who somebody is for the rest of their life and should never exclude somebody from access to care for depression and common anxiety problems.

Vicarious trauma Vicarious trauma, which is sometimes known as secondary traumatic stress or secondary trauma, is related specifically to the impact on the practitioner who works empathically with people who are affected by traumatic life events. Hearing accounts and working with the effect of trauma is stressful for the practitioner. Vicarious trauma indicates that the practitioner has been worn down by encounters with trauma-related material in their work. This is more of a risk when the practitioner is not trained or supervised and supported properly to work with that information. A practitioner who experiences vicarious trauma might notice changes in how they think about themselves and the world, they might find that their beliefs about significant values and parts of life, like safety and faith, change significantly in ways that feel unhelpful. Vicarious trauma can also contribute to compassion fatigue and burnout.

Compassion fatigue Compassion fatigue is what it says on the tin. The ability to offer compassion (I am defining compassion as a kind and nonjudgemental intention and commitment to relieve suffering) is worn out by constant stress and demand. It may involve the loss of the ability to recognise the common humanity between you and others. For many people who work in a caring profession compassion is a fundamental and highly valued personal attribute. Losing access to the ability to offer compassion can be devastating and compound whatever difficulties have contributed to that loss.

Burnout Burnout is one of those widely used words that you already have some ideas about, but you probably haven’t thought about the dictionary definition. The World Health Organisation defines burnout as ‘an occupational phenomenon’ that is the consequence of chronic workplace stress. Stress, in turn, is described as ‘feeling troubled or threatened by life’ (World Health Organization, 2020). Burnout is not a mental health condition but is a state of mental, physical, emotional, and spiritual exhaustion that reduces your ability to do your work. Burnout can be experienced by anyone, but is particularly widely recognised amongst people who work in caring professions. Both vicarious trauma and compassion fatigue can contribute to burnout, but you can become burned out without experiencing vicarious trauma or compassion fatigue. Burnout tends to be the consequence of a few overlapping elements. There are risk factors for burnout in: 1. The individual professional; our personality and internal resources, how we self-manage stress 2. The population who we serve; are the problems our patients bring overwhelming, can we do anything substantial to help? Do the demands made outstrip our resources to keep meeting them? 3. The systems that we work within; work environments can be a direct cause of stress. In my chapter on training and competency (Chapter 3), I mentioned the work of clinical psychologist Dr. Michelle Wilson from University College London whose research is focusing on compassion within healthcare professionals and embedding compassion within their core training. In a conversation about her work on self-compassion for psychological practitioners, Dr. Wilson reflected on the significant systemic pressures that low-intensity practitioners work in. Within this context, she underscored the importance of interventions aimed at supporting healthcare professionals not being solely focused on them as individuals (i.e. what can the individual do to help themselves), but needing to also target systemic level cultural changes (i.e. what can this team/service/organisation do to help individuals), and the value this bidirectional approach could have for all (practitioners and patients). Her reflection was that ‘the former is often prioritised, which inadvertently places (full) responsibility on the individual for their wellbeing, when often system level factors significantly

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impede the benefit these individual level interventions can have. There is a need for research that can speak to how system level factors such as targets and workloads, might interact with individual factors such as self criticism and the exceptionally high standards that many of our practitioners hold themselves to. That interaction, of the person and the system, has not been properly explored yet and there is a tendency to attribute burnout to the individual rather than the system, without acknowledging the interaction of the two’. I am not putting the emphasis on the individual practitioner in this chapter. That has been tried, repeatedly, by employers, and it has failed to make any difference to the volume and impact of burnout in the low-intensity workforce. I am more interested in the other contributing factors, particularly the systems that we work within. It’s important to emphasise that burnout is not inevitable. There are low-intensity practitioners who do this work for years and who do not burnout or experience the difficulties that I am describing here. It is still important to acknowledge that most low-intensity working environments are rife with risk factors and consider if these can be reduced.

Sick leave I hear increasingly from PWP’s who are frightened to go to work and dreading the day, who are exhausted and who struggle to sleep and to solve problems, who might have stopped having much of a social life. They are unwell and have been made so by their work (Fig. 7.5). Feeling that way, to a greater or lesser extent, they probably shouldn’t be in the responsible position of offering psychological care to what can be a very vulnerable patient population. The terms and conditions of work in the NHS are very generous and most low-intensity practitioners still work in the NHS, so why not use paid sick days to rest, get some balance back in your life, and recover?

FIG. 7.5  An image representing the wounded healers who work in the IAPT programme. (Credit: Natalie Hanley.)

In a conversation with a low-intensity practitioner trainee recently, the trainee described that they had the opportunity to observe what it was like to work in an IAPT service before they joined the team as a Psychological Wellbeing Practitioner trainee. Their observation had led them to understand that this is a high-stress job, and they had started their training in the belief that time off sick with stress was an inevitable ‘rite of passage’ into the role. I’m not saying that it doesn’t happen but, in my experience, there are very few practitioners who use sick days lightly. We tend to stay in work quite desperately because time off means returning to a huge volume of work as your current patients are rearranged and you must help to catch up on any lag in access targets. Time off means an increased workload on return. There is also, in most teams and individual practitioners, a powerful sense of responsibility towards patients and a genuine desire to provide the best service possible. Every practitioner knows how long patients have to wait to get an appointment with IAPT, no one would cancel an appointment with a patient lightly. The fact that sickness absence due to occupational burnout is experienced as inevitable is damming and must be addressed.

Loss of reward We work for pay. Each of us has an occupation because it provides a financial income that our households need; psychological practitioners are not (rich) saints who do this job purely for the love of the work and a desire to do good. That said, the lucky amongst us do tend to gravitate towards occupations that are a good fit with our personal values and

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that provide the softer rewards of a sense of accomplishment, mastery, and achievement. Many people who come into psychological practice do so because they value connection with other people and have a deep-seated commitment to relieve suffering wherever possible. There can also be satisfaction for intellectual curiosity and the desire to learn in this type of work. When you are working with burnout these rewards get lost. You are not able to do your best work when you can’t solve problems, when compassion fatigue has disrupted your sense of connection with others. This might lead to poor patient outcomes, or if not that then to a loss of the sense of achievement and mastery. Burnout can make you feel as if your livelihood is under threat because the thought of continuing to work in the same way with the same results is not supportable. My sole was dying and by staying I knew I was being made to break ethical and personal values. PWP (2019)

Complaints and whistleblowing If things are so bad that it isn’t always safe to work in this system, why don’t people complain? In the NHS, there are whistleblowing champions in every Trust, there are human resources teams who you can approach for advice, and there are managerial structures that mean that even if your direct line manager is unsafe or ineffective, there is a hierarchy of people behind them who could potentially be approached for support and advice. People do, in fact, complain. There have been concerns raised to freedom to speak up guardians when the implementation of IAPT, and the use of low-intensity practitioners in particular, seems potentially dangerous or harmful to the public. Human resource advisers have been approached when management is exploitative or bullying. Some people have sued, some have gone to the press, which usually meets with a rapid response of denial and minimising from the national clinical advisors who are far removed from the day-to-day realities of how IAPT is implemented around the country. In short, every door that might have help behind it has been pushed somewhere and still, nothing has changed. One reason for this is that conditions at IAPT are echoed across the NHS, the exploitation of the workforce is taken for granted. The reward of knowing that you are doing good through your work is supposed to compensate for any deficits in pay and safety. When an individual concern is raised, the IAPT standards are the most common reason given for maintenance of the status quo ‘it’s out of our hands, we have to adhere to the national targets, we can’t make local decisions on targets. [Or] We need everyone pulling their weight if we’re going to meet our targets’. This can sound reasonable in the moment and most practitioners want to do their share of the work. They might feel that the national targets must be reasonable and achievable, even if the local context adds unanticipated levels of complexity to what those numbers mean in practice.

If a practitioner approaches their manager because of burnout, the lens is most often turned away from the organisational or patient population factors that might have contributed, and onto the individual practitioner. ‘Are you taking your lunch break, have you been for a walk?’ There was a period, within a year of my qualification as a low-intensity practitioner, when so many members of my team required sick leave due to burnout (I was amongst them) that the occupational health team contacted my line manager to ask what was going on. My manager

laughed when he told me that his reply had been ‘some people just can’t manage the stress of working with people like this, they just aren’t suited to this type of work’. I continued as a low-intensity practitioner for nine more years after that conversation but the doubt never left me; when things were very difficult I wondered, maybe I wasn’t suited to this line of work? It’s important to work on PWP wellbeing and look into the bigger picture rather than artificial changes, e.g. ‘have lunch together’. PWP (2019)

Go private? There are a growing number of private organisations that offer psychological interventions in a stepped care system. These organisations sometimes have contracts with insurance providers, provide wellbeing services to companies, or have contracts with IAPT teams. In partnership with IAPT services these companies essentially expand the capacity of an IAPT team where their existing staff teams can’t keep up with waiting time and access targets.

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As employers these companies tend to be good. They maintain the same standards for training, qualification, registration, and supervision that are required in IAPT. They usually pay a reasonable hourly wage (without the same benefits of paid sick leave, enviable pension plan and paid holiday that the NHS offers), and the practitioners have usually got control over their own diary, deciding how much clinical work they will do, and when they will do it. The downside is that these services charge the partner IAPT team quite a lot of money. Some, but by no means all, will cherry pick the people who they are prepared to work with. If an IAPT team has a high proportion of complex referrals some private companies will work with the small proportion of people who want help with simple mildmoderate depression and anxiety; in those situations, the practitioners employed directly by the IAPT team have to manage the complex work. This means that the direct employees can be left with caseloads that are not well matched to the level of care that they can provide. Of course, this contributes to everything that I have covered in this chapter so far, and potentially has knock-on effects to the diversity of our workforce and the future of how training and service provision is managed.

Plugging the gaps There is a substantial cost to training as many new practitioners as we train every year. The 2021 IAPT workforce census shows that between 2019 and 2021 the number of qualified PWPs rose from 1713 to 2149 (an increase of 436) and the number of Senior PWPs rose from 314 to 431 (a welcome increase of 117). In the same 3-year period, we trained 3498 new low-intensity practitioners. Even my rough, back of the envelope mathematics can work out that those figures don’t add up; trainees are not translating into qualified practitioners within the programme, and in 2021, the proportion of trainees (1520) to qualified and Senior PWPs (a total of 2580) is worrying and speaks to plugging the gaps in services with a high volume of inexperienced practitioners with not enough experienced staff to supervise and support them. This is speculation, but it seems likely that public funds will not be indefinitely available at current levels. The number of practitioners trained must start to result in a stable workforce that is available to provide care and treatment in the communities whose health budgets contribute to training costs. Publicly funded and salaried training makes the psychological professions accessible to people from socio-­economically deprived backgrounds and makes it possible to hope for diverse and representative professions. The loss of staff to better pay and safer working conditions in the private sector poses a real risk to diversity in the psychological professions and needs to be addressed. A solution would be a type of indentured servitude to the NHS. ‘If we pay for your training, you are contractually obliged to stay’, even when there are significant benefits to leaving, even if the working conditions that we maintain are dangerous for your health. The other option would be to make conditions in the NHS safer and more rewarding.

Consequences This is the picture as I have seen it, and within this system, the practitioner has two options. Option one is to stay, the other is to leave. There are hundreds of people who have stayed for the love of the work and for the reward of building a career that feels meaningful and rewarding; for the sake of doing good in their local communities. Retaining practitioners builds a body of expertise and best practice for this approach to psychological care. It raises the quality of the clinical work that we deliver when supervision is provided by people with substantial experience as reflective practitioners in this specific approach. We don’t want the people who do stay to do so at a steep personal cost though, surely? Option number two is to leave the profession. In July 2022, I recorded a short video on the topic of this chapter. The video was my contribution to a ‘Faces and Facets of Practice’, a day-long event organised by the British Association of Behavioural and Cognitive Psychotherapists (BABCP) appended to the organisations’ 50th anniversary scientific conference in London. The event recognised and celebrated the development and value of low-intensity CBT in the four nations of the United Kingdom, and in more fields of application. I wrote my slides on this topic and came to this end point. So many people leave that we don’t have many stable teams, and this has slowed our development as a unified professional group. I wondered why. Tom Fisher, a Senior PWP and coadministrator of a Facebook group for PWPs in IAPT with more than 3 thousand members (equivalent to three quarters of the current PWP workforce!), shared some thoughts with me. When I approached Tom, my question was ‘where is the community of practice? Where do people go to consolidate their learning and deepen their understanding of this approach?’ Tom’s reply was this: ‘I can’t think of many places where people are focused on consolidating practice unfortunately. I think the working conditions for so many people aren’t great, and they focus on when they’re getting out so that they can stay well now’.

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The consequence of the loss of practitioners is an imbalance in the ratios between experienced and inexperienced staff that slows down the development of low-intensity interventions as a modality. We also have too few staff who can provide that depth of supervision, which is truly restorative and that builds up people’s skill. Further reading I have summarised my perception of some of the factors that might contribute to the difficulties with retention that we know we have. Liz Kell and Claire Bagley completed a Psychological Wellbeing Practitioner retention report for the North West Psychological Professions Network, published online in 2020, which makes excellent further reading and is available online (Kell and Bagley, 2020).

So what are we going to do? The images in this chapter were designed and drawn by low-intensity practitioner and educator Natalie Hanley. In Fig. 7.5 we have got the practitioner and the patient’s hands, both equally hurt, to represent the fact that IAPT is staffed in high proportion by people who have experience of common mental health difficulties, just like their patients. The system that I have described in this chapter can sometimes make those difficulties current, but the practitioners continue to offer care. This image recognises the concept of the wounded healer that originated with Carl Jung and has been developed by others, including theologian Henri Nouwen, who describes the idea in this way: ‘Nobody escapes being wounded. We are all wounded people, whether physically, emotionally, mentally, or spiritually … When our wounds cease to be a source of shame and become a source of healing, we have become wounded healers’ (Nouwen, 1994). Because of the system that I have written about, and because common mental health difficulties are genuinely common and psychological practitioners are not exempt from their humanity, many low-intensity practitioners feel that they’re working with a difficulty in their own wellbeing, whilst they are there to help people who are also having very similar struggles. How do we make that safe? My suggestions, these are not hard and fast, I can’t back this up with a reference for you, but what I would suggest from experience would be:

Understanding interpersonal elements A first step would be to do some training to improve recognition of the interpersonal elements of low-intensity work. James has written two chapters in this book about the importance of the interpersonal elements of low-intensity practice so I won’t expand on it too much here. I will just say that some appointments with patients are exhausting, some are refreshing, and it wasn’t always obvious why that was. A model to understand what was happening in the human-human interaction between me and my patients that produced those different effects would have been helpful. A better understanding of interpersonal dynamics could support effective reflection on practice and inform practitioner’s clinical decision-making during an appointment. It could also support more effective supervision in its function to prevent burnout and help with the planning and decision-making around a course of treatment in the service, not just with an individual practitioner.

Handover Have a policy for handover arrangements when work with an individual will be psychologically unsafe for a practitioner. One of the things that was personally very difficult for me was working in my local community and hearing the dreadful experiences that my patients had had less than a mile from my own door. That proximity was wearing, and it affected my sense of safety in my home and neighbourhood sometimes. It would have been helpful if there had been a system where I could say ‘I’m currently overwhelmed by session content on [a specific topic], another practitioner will need to provide treatment for this patient where [the named topic] is going to recur at every session’. And there be a seamless transfer of the patient’s care to another practitioner.

Acknowledge the burden of responsibility High-volume, low-intensity practice involves learning about the circumstances and events of hundreds of people’s lives. We hear these stories whilst engaged empathetically with the person and feeling a sense of responsibility to help. This ties in with that idea of ‘hit and run’ exposure to trauma in our clinical work. The fact that this happens must be acknowledged

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and adequate supervision has to be provided to support the practitioner to work with and sit comfortably alongside the ­distressing material that they encounter, whilst reducing the potential for vicarious traumatisation.

Allow some time Above all, and this is absolutely at odds with the target-driven cultures that we tend to work in, time needs to be allowed for reflection and high-quality supervision. Micromanagement aims to squeeze the maximum possible amount of measurable work out of a practitioner in the time available. ‘Thinking time’ and time for reflective and restorative supervision are the opposite of this. Less tightly managed patient contact time might make achieving activity targets challenging, and the outcomes won’t necessarily be quantifiable. However, that idea of time to think resonated with people who heard me deliver this material in my talk at the Faces and Facets of practice event. It’s what practitioners need to stay well and improve their work.

Progressing a career There is a chapter in this book on professional identity that covers this matter in more detail; here I will briefly acknowledge the element of frustrated career progression that I included in my mind map. Establishing a new profession isn’t the work of a single decade, and we have still got some way to go. Our current state of development as a modality and profession is inevitably a source of some of the barriers to career progression that practitioners can encounter. So, what are the things that might help to reduce the impact of progression frustration and how it currently affects practitioner wellbeing and retention? First and foremost, there needs to be more recognition of low-intensity practitioners as expert in their own modality. That would involve recognising that low-intensity psychological practice is a distinct modality, an addition to the other psychological professions, and that the people who’ve been doing it for a whilst really do get very good at it. Alongside this, we need a recognition of the value of low-intensity psychological interventions, as delivered by trained, qualified, and registered low-intensity practitioners. Supervision An example of where this isn’t happening is in the situations where practitioners of other modalities provide supervision for low-intensity practitioners. If I suggested that a counsellor should provide supervision for a CBT therapist, or a CBT therapist for a counsellor, everyone would know that idea was bizarre. We still encounter the assumption that anyone with a ‘high-intensity’ therapeutic qualification can safely and effectively supervise low-intensity practice which devalues the specific skills and competencies that are developed by low-

intensity practitioners and leads to clinical drift. Of course, in teams that are unable to retain low-intensity practitioners for more than a year or two beyond training, the low-intensity expertise to provide really effective supervision might not be available in the team. I would suggest at that point that we need a system for accrediting low-intensity supervisors so that teams can buy in appropriately skilled and experienced supervision until their practitioners develop the expertise to bring supervision back in-house, instead of allocating any available CBT practitioner to fill the gap.

Role definition Organisational barriers that prevent low-intensity practitioners with no other professional qualification from applying for formal leadership positions should be identified and removed. Alternatively, some teams recognise the great skill and potential in the low-intensity workforce and create new roles that carry formal clinical and operational leadership responsibility. We saw that in the outcomes from the IAPT workforce census, which showed the number of Senior PWPs growing steadily over the last 3 years. A national framework for the job description and person specification in different low-intensity roles would be very helpful. Many teams have Senior, Lead, and Clinical Lead positions for PWPs, but the tasks and responsibilities attached to these job titles can vary significantly between teams. This would tie in with better recognition of the transferable skills that low-intensity staff possess. During another BABCP low-intensity special event in 2019, Lisa Atkinson gave a brilliant talk titled ‘PWP Skills: What do we know and what do we need to know?’ During which she detailed the numerous core skills and competencies that low-intensity practitioners become experts in. Her list included: ● ●

High levels of interpersonal skills which enable effective rapport building within a 45 min assessment Awareness of the symptoms of a range of mental health disorders and knowledge of the NICE recommended treatment for each one

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●

● ● ● ● ● ●

Set an Agenda, review progress and learning, provide information and education and end the session—in a collaborative manner—in 30 min Extremely effective organisational skills Having the clinical judgement to find the balance between Socratic questioning and giving direction Develop self-reflection skills and make the best use of supervision Assess readiness for change and implement techniques to increase readiness for change if needed Manage group dynamics in psychoeducational classes Work with complexity whilst maintaining fidelity to the model

Because we do work with so many people, we become expert in these skills very quickly. Low-intensity practitioners are an asset to a team and their skills and abilities need to be recognised.

Specialisation In that target-driven environment, the opportunity to develop areas of specialisation can provide opportunities for learning and intellectual stimulation that can be protective against burnout. When I say developing areas of specialisation, that could involve several different changes to the working week, time would need to be allocated for it and contact number targets reduced. These are some of the ways that I have seen specialisations develop, this list isn’t exhaustive: ●

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● ●

●

A practitioner develops working relationships with NHS teams or third sector and charity organisations that provide services in the area of interest. This might include anything from a simple introduction to provision of training to staff, to brief interventions that are developed and delivered together, to co-located clinics, to true integrated working of the type described in Chapter 11 on working with long-term conditions. A Practitioner has clinic time that is dedicated to patients with a specific characteristic/who are affected by the area of interest. A practitioner has a role within the team as someone who can be consulted for advice and training in the area of interest. A practitioner carries out service evaluation related to the area of interest and plans new interventions or recommends alterations to policy and practice based on the evaluation. A practitioner takes up a ‘champion’ role which involves some or all of the above. There is a risk of champion roles being tokenistic or exploitative if no time is allowed to develop work in that area into something significant.

Examples or areas of interest that have been developed by low-intensity practitioners include working with parents in the perinatal period, working in the crossover between common mental health problems and substance misuse, working with the Deaf community, adapting services to be accessible and suitable for members of the LGBT+ community and people with minoritised gender and sexual identities. Working with religious communities to provide education on common mental health disorders, and adapting services to be culturally accessible … The list goes on. The Excellent IAPT Black, Asian and Minority Ethnic Positive Practice Guide emphasises the importance of building relationships between IAPT teams and the communities that they serve. That takes time and commitment, it isn’t a one-off task, and it is work that low-intensity practitioners are often capable of doing well, when they are supported and enabled to do so. Managers and service leaders can look for ways to train and develop low-intensity practitioners into areas that really float their boat. Currently, they can only do that by putting the whole service’s target achievement at risk, but some flexibility could be built into national targets to create the capacity for more of this type of work.

Negotiating targets The image above was designed to capture what the low-intensity working week can feel like in an IAPT service (Fig. 7.6). The practitioner is walking a tightrope, juggling the multitude of tasks that they have to undertake whilst underneath, those targets circle; recovery, waiting times and access. What can services do to turn the tightrope into a safer walkway?

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FIG. 7.6  An image representing the balance of daily tasks and the target-driven culture in IAPT services. (Credit: Natalie Hanley.)

My suggestions would be to start by being aware of when practitioners are expected to provide high-volume, highintensity care, that is, working with complex problems and try to stop it. High-volume low-intensity interventions aren’t designed to hold complex presenting problems. Particularly when the complexity relates to clinical risk and safeguarding concerns, those presentations that are sometimes labelled ‘personality disorder’, and trauma, when trauma is actively affecting the patient and is a focus of care. If the nature of referrals to the service are such that complex presentations are a high proportion of the work done by the whole team, then the volume of contacts must be reduced and practitioners given additional training in how to differentiate cases where a specific, simple, problem can be isolated from the whole picture for some work, or when the problems faced by the patient are so enmeshed that a low-intensity intervention is unlikely to be of any real benefit to a patient. They must be supported to signpost effectively and step up where appropriate. Pressure on recovery targets has to ease up in these situations and a focus put on clinically reliable improvement.

Recognition On the monthly review of service outcome data, can you take the opportunity to recognise the contribution of the lowintensity practitioners to the team? Disseminating congratulations for the proportion of recovery that takes place after a low-intensity intervention is meaningful, as is recognition of the role of low-intensity staff in managing waiting times and making the front door of the service accessible and engaging. If your low-intensity practitioners are effective in building working relationships with the high-intensity practitioners and facilitating good use of stepped care, can their organisational and interpersonal skills be recognised? Many low-­intensity practitioners have supervisory duties, can their leadership skills and their role in improving the quality of the clinical work provided by the team be acknowledged? Line management meetings are a forum where this can happen, but more public service-wide recognition is meaningful. Lizzie Gray, Low Intensity Lead from Health in Mind, Sussex, spoke eloquently at an IAPT National Networking Forum event in 2021 about the importance of connecting with the meaning behind the numbers in the IAPT targets. Lizzie in turn acknowledged the work done on this by Kevin Rozario-Johnson of the same service. If targets are going to be prioritised in service design and delivery, it’s important to keep an emphasis on the experience that the numbers represent. Those sharks: waiting time recovery and access are a story, aren’t they? That’s the person who’s in trouble seeking help, trying to get access to that help quickly and get access to the right help quickly. Everything that we’re talking about in this chapter could contribute to a better story for that person because care will be better when it is provided by practitioners who feel safe, valued, and well.

Gaslight … I’ve used the word ‘gaslight’ in this heading with caution; this communication technique is often a feature of ­controlling and abusive relationships and I do not intend to minimise the horrors of domestic abuse. Gaslighting is a manipulative technique where a person, usually a person with more power than the other person in a relationship, casts doubt on the other persons’ judgement and reality. The victim of gaslighting often feels that their sense of reality becomes uncertain, they can feel isolated, helpless and have their belief in their own judgement and worth significantly undermined.



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Why is this relevant in a book about low-intensity psychological practice? Well, I have watched for years as one practitioner after another has raised concerns about the impact of the demands of the IAPT system on their wellbeing (Fig. 7.7). One after another, these practitioners have been ‘dealt with’ in private meetings and the outcome has almost always been a deflection of blame away from the system and onto the practitioner themselves. Even on a service-wide level when ‘wellbeing’ is the topic of a meeting or some training, the usual focus is on self-care routines and personal resilience. There is absolutely an element of personal qualities and behaviour in the risk of burnout, but it is only part of the picture, and it is useless to address this element and ignore the patient population and organisational factors that also contribute.

FIG. 7.7  An image representing burnout in the IAPT programme. (Credit: Natalie Hanley.)

The way that practitioner concerns about burnout are addressed can contribute to the problem. Although the practitioner initially thinks that their experience of burnout is a result of the demands and pressures of their work, they end up believing that their personal qualities, coping strategies, and resilience are entirely at fault. It’s a dreadful thing to experience and witness. When someone comes to you and they say, ‘this work is making me ill’ the response should not be ‘You’re not doing enough self-care’ or ‘You’re wrong, everybody else is coping’.

… Or learn We need to learn, don’t we? As a system we need to do the same reflection that we ask our practitioners to do about their own work. IAPT, or the provision of high-quality psychological care for the quarter of our population with mild-moderate depression and anxiety, is phenomenally important. Low-intensity psychological interventions do a huge amount of good for millions of people. But we have taken an assumption that this system was set-up right and well. Maybe it is time to step back and do a reflective cycle as a system, really look at what is happening and ask ‘is it working?’ We need to learn from what is happening; in too many cases what is happening is a lot of people getting poorly within psychological services, and a lot of people choosing not to stay.

Top tips: Do’s As we bring this chapter to a close, I will summarise with some ‘top tips’, what I think might be important takeaway messages. 1. Take staff wellbeing seriously 2. Support staff to access freedom to speak up, HR support, wellbeing services 3. Encourage Union membership 4. Be a shield, not a shower 5. Take account of the number and complexity of clinical contacts, not just the hours 6. Provide meaningful development opportunities

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In short, take staff wellbeing seriously. Make sure, in particular that staff with minoritised identities who experience overt and covert discrimination within your teams are believed and appropriately supported. Commit to effective allyship on an organisational and individual level. It would be more comfortable if I write this chapter and don’t take the opportunity to shout ‘workers, unite!’ But really, workers, we need to unite. We need to talk to each other because you get a different perspective on the wellbeing issues when you hear the story coming from lots of different places around the country. That broader perspective can be a great motivation to produce some change. For managers: be a shield, not shower. We all know in an organisation the ‘bad stuff’ rolls downhill. You can choose to shield the people who are hierarchically under your protection or shower it down on them. We see both. It’s important to take account of the number and complexity of clinical contacts, not just the hours delivered. The IAPT manual currently, in version 5, recommends 18–20 h of clinical contact time in a week for a full time low-intensity practitioner. In a 37.5 h working week that might sound like a small number but remember that for a low-intensity practitioner, 20 h might mean 40 people in a week; that’s a huge burden of difficulty and responsibility to carry in the back of your mind. If that’s 40 people who are low intensity appropriate with simple, straightforward mild-moderate depression or anxiety and there is no risk of any kind of harm to anyone in the picture, crack on, that’s very doable. But that’s not the work that we do very often.

Top tips: Don’ts 1. Replicate the same pattern in new roles 2. Attribute struggle to the individual without considering all factors 3. Wait for practitioners to struggle before you do something 4. Micromanage 5. Expect practitioners to work beyond the remit of their role Low-intensity interventions are rapidly expanding into more settings and areas of practice. That means that there is an opportunity not to replicate these same difficulties in those settings. It’s important for practitioners, supervisors, and managers not to wait for something to go wrong before a response is offered. With awareness of the problem and the factors that might contribute to it preventative action might be easier to plan and implement. As a starting point, the struggle of an individual practitioner should not be attributed entirely to that individual without taking account of everything else in the picture of their work life that could be contributing to the problem. This would include the management style that they are working under and what’s expected of them in terms of targets and the complexity of the clinical work that they’re doing. The harms of micromanagement are documented in the research literature from a number of disciplines. Micromanagement is bad for people’s health. So whilst there will always be targets for public services to achieve, it’s important to find a balance in how they are communicated and implemented so that practitioners have some power, choice, and control in their working life. Practitioners can be trusted to self-manage their working day at a pace and in a way that suits them whilst still achieving the goals required by the service, without feeling scrutinised for every decision that they make.

Finally I hope that this journey through some of my top tips and ideas has been useful. What I really want to emphasise is that this work can be done long term, and it can be done in a way that is not detrimental to the practitioners’ wellbeing. Above all, I think it is time that we start to adjust the whole system to ensure that that is happening. That, as we’re there to treat depression, stress, and anxiety, we’re not at the same time causing it in our own teams. Adjustments at that level take time. Whilst we wait, low-intensity practitioners need to communicate with each other beyond their local team, sharing what works. I have heard from some people whose teams do a lot to protect their wellbeing; there are missed opportunities to disseminate best practice.

There’s always room for a sequel After 11 years in IAPT, I have had the opportunity to meet dozens of low-intensity practitioners and, in many cases, observe what their working life was like in IAPT and what they have accomplished after they left. In my experience that was limited to a single, admittedly large, IAPT team for most of my time with the programme the observations have been quite startling. Working within IAPT seems to have a suppressing effect on practitioners. People who I have worked alongside



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left IAPT (burnout was often a contributing factor in the decision to leave) and blossomed into successful academic careers, progressed to exceed in further clinical training, have strategic, consultancy, and leadership roles in various branches of the NHS, and charities. At a leaving party for an old colleague who was retiring out of IAPT, I joked that when you get out of the system you start to breathe large lungs of fresh air again. The words tripped off my tongue with a laugh before I realised that I wasn’t joking. I wonder what would happen if all of that potential was harnessed and given scope within the IAPT programme? The provision of high-quality psychological care for the huge numbers of people in our country who can be relieved of suffering by a brief and simple piece of work is a vision that many of us are committed to. Making room for the potential that exists within the practitioners in the IAPT programme, and the skills that work in low-intensity roles refined, would require a complete redesign of IAPT. It would mean moving away from the ‘command and control’ hierarchical management of the programme that we have now and moving towards a true implementation of collective shared leadership. We would need to go back to the drawing board on how we measure what success and good outcomes look like. There are people who aspire to be low-intensity psychological practitioners who contain the strategic, managerial, organisational, and clinical potential that we see emerge when they leave IAPT. Knowing that, some significant changes might be worth the risk.

References Kell, L., Bagley, C., 2020. What Factors Impact on the Retention of Psychological Wellbeing Practitioners?: Report of a Survey Into Second Destination & Retention of PWPs. North West Psychological Professions Network. Nouwen, H., 1994. The Wounded Healer: Ministry in Contemporary Society. Darton, Longman and Todd, London. Westwood, S., Morison, L., Allt, J., Holmes, N., 2017. Predictors of emotional exhaustion, disengagement and burnout among improving access to psychological therapies (IAPT) practitioners. J. Ment. Health 26 (2), 172–179. World Health Organization, 2020. Doing What Matters in Times of Stress: An Illustrated Guide. World Health Organization. https://apps.who.int/iris/ handle/10665/331901.

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Chapter 8

Navigating relationships and therapeutic boundaries James Spiers

Key aims of this chapter ●

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●

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To understand common problems that can arise with interpersonal boundaries and the challenges of striking a balance between therapeutic complementarity and avoiding clinical drift. To explicitly demonstrate the differences between the here-and-now relationship of low-intensity psychological therapy, and the relationship as an intervention, more commonly seen in relational psychotherapy. To highlight the importance of containing clinical drift and promoting ethical intervention to reduce the potential for low-intensity practitioner burnout and iatrogenic harm. To help low-intensity practitioners be more aware of the processes in systems, services, and local teams that can impact our relationships with patients.

Professional boundaries in human services Professional boundaries are a crucial part of our therapeutic work with patients. Across the majority of the accrediting bodies within the United Kingdom and beyond, there is a general consensus that therapeutic boundaries are necessary to protect both the patient and the practitioner. The British Association of Counselling and Psychotherapy (2016) offers clear guidance. First, patients need to be confident that the service they receive is going to be effective and ethical. In simple terms, we need to ensure that we are working at all times focused on harm prevention and reduction. The limits and ethical boundaries of our training need to remain intact, avoiding the blurring of them beyond our level of experience, knowledge, or qualification. We need to ensure that we are providing psychological safety. This means that we are offering a space where our own biases, beliefs, and judgements are put to one side and that we create conditions where our physical or digital therapy space is safe, and where someone is encouraged to speak about aspects of themselves or their problems that are important to them. Psychological safety also means that we are helping someone to monitor and contain the impact of distressing material, in particular where the person’s history may contain significant experiences of trauma. Finally, we need to offer a flexible but consistent approach. Being too inflexible or rigid with fidelity to a particular way of being over the needs of the person can lead to the therapist being perceived as cold, obstructive, or unhelpful. Our work then becomes counterproductive, despite strict compliance to therapeutic technicality, and we risk losing the patient through drop-out or disinterest. By contrast, too much flexibility such as constantly changing venues, or cancelling appointments can lead to therapists being perceived as confusing or unstable, leading to mistrust. Our work then becomes less adherent to technicalities as well as lacking focus and containment. Striking the right balance can be challenging and varies depending on the person we are working with, the organisational and logistical structure of systems, and the different experiences, traits, and styles of each clinician. We also need to be aware of our own “suitcase of stuff” that as individual humans, we inevitably bring with us to each therapy session.

The mill pond Try to think about a recent experience where your emotions were relatively still. Perhaps you were having a general conversation with a colleague about their plans for the weekend. Whilst there may be a degree of interest, the conversation may not hold any significant emotional connection to your personal experiences or value system, unless you are really Care in High Volume. https://doi.org/10.1016/B978-0-323-88492-1.00008-7 Copyright © 2023 Elsevier Inc. All rights reserved.

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interested in the topic or have difficult associations with it. For most people, it is unlikely there will be strong feelings, and our emotions are a bit like water in a mill pond, flat with a gentle ripple of interest. By contrast, if we watch a debate on TV about our keen interest topic, decisions made by a political party, or a sports match where our home team is playing, we are more likely to experience a stone or rock being thrown into the mill pond. This may create a momentary splash or become mobilised as prolonged swells or waves depending on how strong our personal beliefs and values are associated with what we hear or see. Through our clinical work, we regularly hear content from our patients’ lives that we may interpret or observe as aligning or misaligning with our personal values, beliefs, and experiences. If we fail to properly notice and monitor the mill pond, we may find ourselves responding to our patients based on those splashes, swells, and waves. We might feel overly excited or happy and tempted to join in or collude with a particular narrative. We may experience feelings of anxiety, anger, or envy that mobilise us to challenge, interject, protest, or complain. Equally, if we have no emotional connection, we may see the opposite, disinterest or boredom, missing or overlooking what is important to the patient. Monitoring and managing our responses and reactions during our clinical work are a difficult but essential skill, regardless of our modality. It can also sometimes be personally challenging to think that our feelings being mobilised or immobilised through our interactions with a patient may stem from experiences that may be closer to home than we might ordinarily like to think about. A key component within the low-intensity therapy model is our ability to reflect as practitioners, eliciting feedback from our patients about our work together. This doesn’t extend only to reflecting on patient experiences and thinking about problems and solutions. We also need to be aware of and, to a reasonable degree, open to exploring our own thoughts and actions within our sessions, particularly where this may involve blind spots in our self-awareness that hold the potential to impact the patient. A practitioner may harbour an implicit dislike for a particular patient, perhaps the patient challenges their sense of competency or talks about challenging topics. If we then deny our feelings of dislike for the patient or feel afraid to talk about this during supervision, we may see this appear more explicitly in our actions during our sessions with the patient. Examples might be where a practitioner is quite animated in supervision, advocating for action that feels a little excessive or premature. Sometimes supervisees might present a case for early discharge laced with emotive content with little objective evidence: “I feel that the patient needs a different approach,” “I feel we are not getting anywhere,” or “I think that the patient feels that this is not working.” These are also common narratives during group supervision, where practitioners are talking about their patients lacking engagement and motivation for therapy, in some cases, despite the patient having arrived promptly for each session but not necessarily doing what the model or approach requires them to do.

The wing mirror Imagine that you have just landed from a long-haul flight, fatigued, and hungry and you just want to go home. First, you have to queue and wait to claim your suitcase of stuff from the baggage carousel. There are two suitcases that look identical to yours but with very subtle differences. Your eyes are tired, you feel impatient due to the fatigue, and you grab the first one coming off the carousel. Although this suitcase feels a little different, heavier, you ignore this and without looking back at the carousel, persist in dragging, carrying, lifting, all the whilst becoming even more exhausted. You eventually get home and open the suitcase only to realise that none of the contents are recognisable to you. Needless to say, a second glance up and down the carousel before you left the airport would have likely paid off. We are also presented with narratives in our clinical work that may appear on the surface to be similar or somewhat recognisable to our own, if we are not aware of our blind spots, then how do we identify whose suitcase of stuff is whose? Unless we have good self-awareness, then we risk grabbing the wrong suitcase from the carousel and unnecessarily carrying the weight of the contents. Equally, if we do not keep hold of our own suitcase, then we risk our patients taking ours home by mistake. The depth to which personal reflection may be needed will depend on our way of working as well as our own histories. Dynamic and relationally oriented modalities commonly require training therapists to undergo personal therapy as working at a deep emotional level with a patient can give rise to powerful feelings on both sides of the room. Modalities such as cognitive behavioural therapy (CBT) and low-intensity CBT (LICBT) have no mandatory requirement for personal therapy whilst training, but this does not mean that CBT therapists or LICBT practitioners do not need to develop good self-awareness, we still need to regularly check for blind spots in our wing mirror and monitor our emotions in the mill pond.



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Therapist effects Large meta-analyses have found that most evidenced-based psychotherapy treatments for depression have efficacy (Wampold et al., 2002; Wampold and Imel, 2015). Although different modalities evidence their outcomes in different ways, there is no front runner, with relational approaches being equally as effective as CBT (Pybis et al., 2017). Personcentred experiential therapy (formerly counselling for depression) has also shown similar outcomes to CBT for depression in a recent comparison study, albeit with an increased likelihood of longer term effects when using CBT (Barkham et al., 2021). However, there are common factors across all psychotherapeutic modalities that can influence patient outcomes. Regardless of modality, something that the therapist is personally doing or not doing in their clinical sessions can determine how successful the patient is in therapy (Johns et al., 2019). Therapist effects not only impact outcomes but also impact engagement and premature termination of therapy (Saxon et al., 2017). There is also some evidence to suggest that as therapists, we can also have a tendency to overestimate our personal effectiveness (Dew and Reimer, 2003). This is really important for all therapists to know whether we are working in specialist, high-intensity, or low-intensity intervention when we consider that our own individual way of working in our sessions with patients may hold the potential to advantage or disadvantage their outcomes and engagement. Of course, we all hold the potential for biased thinking based on our own experiences. It also makes sense that therapists who are trained in a particular therapeutic modality will hold biases towards their own model of working. If you are a therapist and you believe in your model and you see good outcomes for patients and it aligns with how you view human distress, then naturally you are going to hold some degree of hesitancy or potential criticisms towards a different way of working. Despite our biases, it is common to hear low-intensity practitioners talk about patients not doing out-of-session homework or not attending sessions, and there is a tendency to talk about this in terms of the patient having a lack of motivation for change. In many cases this may be true, we obviously have to respect our patient’s choice to consent to treatment. However, from my experience in the role, the general tendency in low-intensity supervision groups is to lay blame for dropout almost entirely on something that the patient is or is not doing. This is a particularly common discourse when there is pressure within services to maintain high throughput to meet access and waiting list targets.

Challenges with engagement The current trend according to NHS Digital (digital.nhs.uk) is that around 75% of all referrals to an IAPT service do not successfully complete treatment. These data are often cited as one of the criticisms of the IAPT programme, with particular concern around the efficacy of treatment outcomes based on the large investment from the public purse. What is often overlooked within those criticisms is that these data also contain a vast amount of low-intensity assessment appointments with a follow-up signposting session, counting as two appointments. Patients are also commonly misdirected to IAPT services, where social housing or welfare needs are the person’s primary focus, or where there is no reasonable or safe way of supporting the person in brief primary care intervention due to high levels of risk, complex interpersonal problems, or severe and enduring mental ill health. However, this is unlikely to fully account for the very high drop-out rates in IAPT services. For the patients for whom IAPT services are designed to support, where there is a degree of safety and the presenting difficulties are described as ‘mild to moderate’, the sparse amount of research considering drop-out and disengagement is typically qualitative. This means that by its nature (lived experience) tends to be small participant numbers. Whilst small qualitative studies are unlikely to create major shifts in terms of government funding or decision-making, the data from these studies are no less important, particularly when we consider the overarching themes being generated.

Patients who drop out of treatment The most common themes drawn from the qualitative data are that drop-out and nonattendance within primary care psychological services such as IAPT are in part down to what is happening within the therapeutic relationship, rather than the entire story being about patient readiness or willingness to change. For example, Marshall et al. (2016) proposed that nearly half of nonattendance in IAPT services is due to the rigidity of the service and practitioner contributions to the relationship. Amos et al. (2019) found that the subjective patient reporting of the least helpful components of low-intensity therapy was a lack of time to talk and a nonpersonalised approach. More recently, a larger study of 818 patients (Ghaemian et al., 2020) again found that one of the themes influencing drop-out was a breakdown in the therapeutic alliance. Here, we might pause

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to consider whether our own willingness to engage with criticisms of our model from those who use it and therefore our own room for thinking and readiness for change at both at an individual and a systemic level might be impacting patient engagement and the potential for improved outcomes.

Relational drift Anyone working as a CBT therapist or low-intensity CBT practitioner will likely have come across a paper by Waller and Turner (2016). The authors claim that around a third of CBT therapists believe that the therapeutic alliance alone is sufficient to drive therapy outcomes but found very low evidence to support these claims. Yet, the paper does not imply that the relationship is unimportant within CBT-based approaches, they simply highlight that the technical change methods (models, diagrams, diaries, and written materials) are considered to be the main therapeutic tool in this model of working. They do not discount the requirement for a strong therapeutic alliance to facilitate engagement but suggest doing this with fidelity to the research basis underpinning the change method in CBT. This is also the main paper that low-intensity practitioners typically cite in a counterargument when I have approached the topic of the therapeutic relationship in low-intensity interventions at various forums and training events. Their rationale being that (as in CBT) low-intensity CBT outcomes are not driven by the therapeutic alliance alone; therefore, the primary focus should be on the relationship between the patient and the guided self-help (GSH) material. My take on this is that this response often masks a wish to retain familiarity with the status quo, which, in turn, maintains distance within the lowintensity relationship. Rather than a biased belief that the low-intensity therapeutic relationship is less important than the technical intervention, I consider this more in terms of practitioner anxiety about clinical drift, or “how do I do this without drifting?” My personal opinion here is that it is more a case that relational factors are more difficult to be thought about within the current low-intensity framework, as opposed to any research evidence to suggest that the relationship between the patient and the practitioner in LICBT is of limited use. To labour the point here, low-intensity intervention does not work as well without a good therapeutic alliance, whether this is computerised CBT (Pihlaja et al., 2018), telephone-based treatment (Turner et al., 2018), or traditional face-to-face interventions (Amos et al., 2019; Marshall et al., 2016). The therapeutic alliance between a patient and the low-intensity practitioner is as integral to facilitating the person’s engagement with the change method as the change method itself. Critics of CBT-based approaches will often paint the picture that the relationship is more akin to applying for a mortgage than an empathic therapeutic experience. In Kennerley et al. (2017) An Introduction to Cognitive Behaviour Therapy, their chapter on the therapeutic alliance seeks to dispel this as a myth. They consider the relationship in CBT as a ‘useful laboratory for working on problems’ (p. 45), which offers the patient an opportunity to try out and develop (and make mistakes with), new skills and tools. The skills and tools can then be practised in a psychologically safe and contained space in therapy to then gradually become more generalised to the patient’s day-to-day life. Chaddock (2013 cited in Kennerley et al., 2017) also implied that paying particular attention to interpersonal factors is even more important in low-intensity psychological therapy, mostly due to the requirement of needing to develop a strong relationship in a short space of time, often with long gaps between sessions. I might also add to this that as low-intensity practitioners are increasingly being asked to see high numbers of people who present to services with challenging social contexts and higher severity of psychological problems than the role was initially intended to work with, the relationships with our patients then become even more important in order to navigate complexity during our assessments, but also to monitor the impact of all of this on our own wellbeing.

Therapeutic content and process A fundamental element of any psychological therapy regardless of the modality is the therapeutic process. This is the entirety of what happens during clinical contact or the ‘bigger picture’ during the encounter between a therapist and a patient that leads to change. In other words, this includes the thoughts, actions, and emotions of everyone involved in the therapy space; the interpersonal relationships between the people involved; and the explicit research basis for the approach being used. I will cover process issues in low-intensity therapy in more detail in Chapter  9, Reflecting on Interpersonal Practice. The term content quite literally refers to what is said and discussed within a therapeutic space. As a low-intensity practitioner, the content is typically psychological education and information given from written materials and visual resources. The content brought to therapy sessions by our patients will vary significantly depending on their presenting problem, the source of their problem, and their life context. From my personal experiences of supervising low-intensity

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practitioners, common problems arise within the therapeutic process when the focus is purely on material content resulting in a distanced relationship. This can often lie within the common confusion and grey areas articulated by newly qualified practitioners around what their role with the patient actually is, and what the boundaries of the therapeutic process are.

Low-intensity coaches There have been varied accounts and explanations of the low-intensity relationship discussed within various forums and continuous professional development (CPD) events that I’ve attended over the years. The most common is the relationship between the low-intensity practitioner and the patient as “coaching,” or [t]herapy with a small ‘t’, delivered from a distance (Fig. 8.1). Personally, I find the concept of low-intensity therapy as coaching to be both problematic and an inaccurate description of coaching. The International Coaching Federation (coachingfederation.org) writes, Coaching is a thought-provoking and creative partnership that inspires clients to maximise their personal and professional potential, often unlocking previously untapped sources of imagination, productivity and leadership.

Whilst varied interpretations of coaching exist, many rooted in the ethos of humanistic, cognitive behavioural, and solutionfocused therapy, coaching is typically focused on occupational or lifestyle goals and change. Whilst it can be common that patients may experience beneficial effects on their lifestyle and occupation as a result of low-intensity psychological interventions, this is not the primary aim of low-intensity psychological therapy. Low-intensity practitioners are trained to focus specifically on the cognitive, behavioural, and physical symptoms maintaining anxiety and depression. They are psychological health clinicians, not coaches. They do not unlock potential around life decisions or aims, career choices, or development. Therefore, conceptualisations of coaching in low-intensity psychological therapy discourages the development of a psychotherapeutic alliance in favour of a purely facilitative role. My thoughts here are of a low-intensity practitioner acting as a football coach, standing on the side-line blowing a whistle and shouting instructions, whilst the team (patient and GSH material) work together to achieve a goal. If the low-intensity practitioner role is simply to help someone to create an alliance with a self-help manual, then the relationship between the practitioner and the patient becomes secondary and automatically on the periphery.

FIG. 8.1  T-shaped relationship GSH-psychological material coach.

If we were to think about this in reverse, for example, a new patient attends a low-intensity assessment appointment and the practitioner asks, “can you tell me a bit about your relationships?” The patient then responds with, “I’ve recently developed a relationship with the 1998 Ford Service Repair Manual and often talk to it about the problems I’ve been having with my car,” our thoughts are likely to jump to this being an unusual belief. Ironically, we do not find this unusual when we are actively asking patients to do just this. If all we are offering to the patient is written psychological material (content) and a distanced human relationship (no attention to the process), then we are simply offering low-intensity psychological content, not psychotherapeutic intervention. My question here is if people can help themselves by developing a truly therapeutic relationship with a workbook, where is the need for human intervention based on psychological assessment, theory, and evidence? Or put another way, why would they need to see a psychological therapist? We see similar issues with the concept of the low-intensity practitioner as a coach in terms of psychoeducational groups, where the focus is purely on the delivery of PowerPoint presentations with little to no [within group] interaction. The group process is an integral part of group therapy (see Yalom and Leszcz, 2020). Yet, the primary aim of low-intensity

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group ­intervention is the delivery of therapeutic coping skills with the interpersonal group process simply coming from the ­encounter of patients being alongside other people who have similar experiences or difficulties. The rest is, albeit potentially useful, information (content). On this basis, it is vitally important that patients accessing these courses are truly suited to and capable of supported self-help.

Low-intensity psychological practitioners From my personal experience in the role, particularly where good outcomes are sustained within challenging social demographics, the most successful outcomes are typically where there has been a strong interpersonal alliance with the patient, whether this is face to face, by telephone, digital video, or live instant messaging. Granted, this is not easy when you are seeing between eight and ten patients a day for very short appointments, nor do I buy into any notion that the majority of people that we see at low intensity will gain permanent change, this is neither the aim nor focus of low-intensity work. However, the clinical reality of the high-volume, low-intensity nature of the work is increasingly being undertaken with more complex moderate to severe (as opposed to noncomplex mild to moderate) presentations. This can be exhausting and often feels unsustainable; hence, I do not blame practitioners for wishing to maintain relational distance, even if the tendency is typically to cite an ‘evidence base’ in order to manage their feelings about it. Guided self-help material provides part of the knowledge needed to undertake the change method, the rest we need to gain empathically from clinical judgement, and the phenomenological experiences of the patient (Fig. 8.2). We cannot account for differences in how psychoeducational material may land if we are simply shouting from the side-line. If we have not provided sufficient safety in our therapeutic space to understand the person, how do we know that someone who discloses trauma is either ready or wanting to engage in a higher intensity of therapy? In contrast, how do we know whether a person who has learned to manage trauma and traumatic nightmares, using excessive exercise, list making, and diary scheduling, is not now sitting with feelings of anger and shame in a psychoeducational group watching PowerPoint slides about ‘recovery’ from depression through improved sleep, exercise, scheduling, and diary keeping? Whether we call ourselves coaches or practitioners is quite arbitrary, the primary aim of our role with the patient is to be real and to help our patients to work with their own realities. We can only do this with thorough person-centred assessments and co-created treatment plans. We can only co-create person-centred treatment plans through human-centred relationships. How we do this will depend on the degree of self-awareness that we hold and our openness to understanding the person we are working with. It is also important that our work is informed by the patient’s experiences, helping us gain knowledge to update and develop the material itself. How can this be done without the development of a therapeutic relationship? It is not the job of the self-help material to form an intimate relationship with the patient. Workbooks cannot navigate the nuances of human understanding nor can they navigate a therapeutic rupture where the generic information contradicts the person’s lived experiences. If we do not clearly communicate the limitations of low-intensity therapy to our patients, how do we gain informed consent? If we do not advocate for patients who require higher intensity or longer term psychotherapy, how do we increase access to psychological therapy? It would be unethical to distance ourselves, silence our patients, and plough on with protocol in spite of its lack of efficacy and relevance. We cannot offer ethical practice without the relationship. By splitting off the human from the process, we can also limit those who are suitable for low-intensity intervention from the opportunity to test out the change mechanism within a safe and contained (albeit brief) space, removing the laboratory in favour of a DIY home testing kit. By positioning ourselves as the metaphorical football coach, we become a customer service helpline in the event that the person struggles with the home testing kit. If we have a patient who struggles to help themselves, will they persist, or is it their impression that no one is interested in helping?

FIG. 8.2  Low-intensity psychological practitioner relationship.



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The laboratory vs home testing kits Naturally, if your home testing kit is aimed at the statistical mean of the general population who have both a cultural and intellectual understanding of home testing kits, the idea of a customer service agent of change becomes more plausible. If we then start to add complex social contexts, diversity, and differences that do not fit neatly within the standardised instruction pack, then the person is more likely to need human understanding and support, or they will simply disengage. Equally, if our staff teams have little understanding of the world beyond the statistical mean, then how do we add value and be able to make a real-world difference for our patients? Those low-intensity, high-volume caseloads are then more likely to result in emotional numbing, distancing, and ultimately impact on patient outcomes and therapist wellbeing (see Delgadillo et al., 2018). We cannot achieve inclusive outcomes and good staff wellbeing if we have overly rigid rules about low-intensity therapy being the equivalent of a therapeutic customer service helpline. How would we explore the impact of loss and be able to pull this apart from a clinical presentation of depression? How do we understand the impact of experiences of racism, disability discrimination, learning difficulties and needs? How do we find out whether depression is linked to sexual problems, including erectile dysfunction, or the avoidance of sexual intercourse based on contamination fears due to OCD? We must work within the clinical reality of real human life, the very least our patients should expect within the therapeutic alliance during low-intensity intervention, is something human. In Chapter 6, Working Inclusively with Gender and Sexual Diversity, I offer a more concrete example of where the less attention we pay to the therapeutic relationship, the further we are likely to drift away from inclusive practice. Also, a significant point here is that low-intensity therapy is preparing to expand beyond CBT-based intervention with the introduction of guided self-help cognitive analytic therapy (GS-CAT). In GS-CAT, there is a focus on interpersonal patterns of relating. How will we then continue with self-practice self-reflection (SPSR) if we are not considering our own interpersonal patterns in relationships, as clinicians?

Clinical drift A common danger that arises when therapists start to work beyond the concept of the coach is a clinical shift from low-­ intensity therapy towards a purely dyadic relationship between the therapist and the patient, similar to that of person-­centred counselling and psychodynamic psychotherapy. Essentially, two people working within a direct relationship using the relationship as the main intervention without technical tools and manuals. This is often where the majority of the confusion and fear resides for newly qualified low-intensity practitioners once they start to develop their interpersonal skills. Once the pressures of working with a high-volume caseload begin, practitioners can often scramble for survival. What typically happens here, based on my own personal observations of supervision groups, is that therapists can become polarised in their approach. They either cling to the safety of protocol and procedure and detach from intimacy in the relationship, which Liz refers to as the manualised practitioner, or the opposite, where they become overly involved and embark on unqualified practice, which Liz refers to as the free for all practitioner. It is also very common for patients to present to therapy services intuitively seeking a dyad: “I’m ready to talk about my problem and wish to talk to someone about that problem.” It can then be a difficult repeated conversation, particularly for people who are expressing an explicit wish for a dyad, for low-intensity practitioners to begin talking about a lower intensity of clinical input with the onus being placed on the patient to engage with self-help: “if you have a problem, talk to the workbook about it!” It makes sense then that the pressures of doing this repeatedly day in and day out may result in low-intensity practitioners doing what they can to cope. It also makes sense that practitioners may revert to their own patterns of coping in relationships to achieve this. How we navigate this can be challenging, particularly in services where they operate a progressive stepped care model, where practitioners often have little choice but to test engagement with guided self-help before the patient can access formal counselling and psychotherapy. What we can then end up with is a patient getting what the service needs to offer, based on resources, rather than what the patient wants or needs, based on sound clinical judgement. Reflecting back on my earlier career, a primary factor in my intentional (but well-intentioned) tendency to drift towards what would look more like a dyad, was my own belief that this was what everyone wants and needs. Inevitably, this was the writing on the wall of me eventually training as a relational therapist. However, in terms of psychological safety, regardless of how well meant my intentions were, without training and supervision in this way of working I was at risk on many occasions of teetering on the edge of unethical drift and opening the door to potential harm. Given that many people presenting with mild to moderate symptoms of anxiety and depression who are suitable for CBT, will likely benefit in some way from LICBT, provided this is well matched to their immediate aims, I was also likely limiting many of my patients

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from benefiting from swift access to something helpful. Essentially, my bias and assumption about patient attitudes towards LICBT muted my ability to offer the patient an informed choice, which was the very thing I was accusing (and still accuse) healthcare systems of doing.

Upward vs downward drift We often focus our attention on prevention of blurring the boundaries of our role in what I term upward drift, where someone is working beyond the scope of their training and knowledge. For example, someone attempting to work with a more intensive model of CBT, inappropriate and uncontained exploration of traumatic relationship dynamics, or linking historical events to the here and now without formal training in doing so. Of course, we all have the occasional slips and make mistakes, regardless of our training background or clinical approach. Equally, there may be occasions where it is more ethical to temporarily drift from our model than it would be to plough on robotically. We are humans working with humans after all. What I’m referring to here are the occasional sessions where someone may have experienced a relationship breakdown, dispute, or loss between sessions, it would be inappropriate not to allow the person some space for us to listen to its impact. These are the common factor skills that we share with most other modalities: empathy, warmth, kindness, and a nonjudgemental approach. However, if for the duration of the treatment episode, we are not doing what we are trained to do, solely relying on an empathic relationship to elicit emotional change, then we begin entering unethical relational drift (as I will example shortly), and the potential risk of harm to the patient increases exponentially if practitioners are not trained to do this. Clinical drift can also appear even when we are working well within the boundaries of our professional qualifications. If we rely solely on technical interventions and neglect our interpersonal skills, we can come across as cold, unempathetic, and robotic. Given that we know from the sparse qualitative data that these are likely factors in disengagement and dropout, the patient is therefore being inhibited from fully benefiting from an intervention. We can then consider this a potential for harm. There is also downward drift, entering what looks more like a social support role. Of course, there are going to be occasions where we spend an entire session offering practical support, perhaps the patient has received an eviction order that morning or has no food and requires a letter to access a food bank. It would be inappropriate not to focus on the immediate need during this appointment. Again, if this is happening for the duration of the treatment episode, for example, six or seven sessions of sorting out social difficulties, then (unless we are working as a social worker) we are entering clinical drift from low-intensity psychological therapy. Whilst regularly offering social support may be incredibly helpful for the person and equally, it may be a very kind thing to do, we need to ask ourselves whose emotions and experiences are influencing this decision. Typically, as much as we may not wish to admit this, it is often the emotions and experiences of both the patient and the practitioner that are involved.

Intentionality of drift There are many factors that may contribute to low-intensity clinical drift, but my personal take is that drift is nearly always something that we do intentionally. I do not mean that we set out to do this maliciously or with a desire to cause harm, but if it is happening regularly, this being a matter of pure coincidence is unlikely. Often, drift happens subtly and on the periphery of our conscious awareness but will in the majority of cases be something that we do based on how we interpret our patient’s needs from our own personal cognitive and emotional processes. If we return to the analogy of the mill pond, when we are anxious or something emotionally disturbs us within a session, perhaps there is something the patient is saying or doing that taps into our own experiences, we may feel the urge to do something outside of our remit and boundaries of training. If we are being disturbed by swells or waves, then something, regardless of how we analyse or frame it, is going on. How is excitement, anger, anxiety, or shame influencing our actions? Whose emotions and experiences are involved?

Understanding therapeutic relationships During the COVID-19 pandemic Liz and I presented some remote access national training seminars around the low-­ intensity relationship with the British Association for Cognitive and Behavioural Psychotherapies (BABCP), and whilst not part of the language of CBT or LICBT, I presented a short section on the topic of transference and countertransference. We were met with mixed and quite confused feedback in terms of the relevance of this to low-intensity therapy from some of the delegates who attended. The primary aim of including this, and what I personally felt was important, is that



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l­ow-intensity practitioners are often left in the dark when it comes to understanding alternative concepts in psychotherapy. If they have nothing to compare the low-intensity relationship to, other than CBT, how do they navigate their practice as being too hot, too cold, or just right? My personal experience of being left in the dark as a low-intensity practitioner often resulted in uncertainty and drove a lot of anxiety about the degree to which the relationship could or should be established. This created a similar polarised position to those that I recognise in supervision groups. I would shift from emotional numbing resulting in defensive rigidity to prevent clinical drift or move towards rescue leading to increased relational drift.

Transference and countertransference There are many schools of psychoanalytic thought and different therapists, and training courses will consider variations in this, and I cannot do justice to its complexity in a few paragraphs. What I am attempting to do here is highlight the more extreme differences in the way the relationship is utilised between low-intensity practice and relational psychotherapy. The hope here is to flatten any temptation or concern that low-intensity practitioners may have about drifting away from ethical low-intensity relationships, specifically when they begin delivering interventions that explicitly address relationship patterns, such as GS-CAT.

Transference relationship A transference relationship is a key concept in psychodynamic psychotherapy and links to our early attachments. Attachment relates to the development of intimate relationships learned through our early experiences of proximity, nurture, and emotional regulation from our primary caregivers. A blueprint or ‘internal working model’ forms in terms of how we relate to ourselves, others, and our expectations of the social world around us (see Bowlby, 1978; Schore, 2017, 2019). In psychodynamic theory, a term commonly used to describe this internal sense of self in relation to others is ‘object relations’, or how the person approaches and relates to another person, people, or thing, ‘an object’, see: Object relations theory: An overview (Cashdan, 1988, pp. 3–27) for a more comprehensive exploration of the concept. If there is trouble or trauma in someone’s early experiences of primary attachment relationships, this can give rise to strong feelings that the infant is unable to manage, leading to psychological conflicts. In order to manage these feelings and conflicts, the infant develops ways of dealing with them, which Freud (1894/2014) conceptualised as defence mechanisms. Based on broader psychoanalytic theory, every human has attachment patterns and defence mechanisms, but most psychologically healthy people will commonly go through life with few problems. For those who experience chronic and persistent psychological distress, this can relate to unhealthy or destructive unconscious patterns of relating and defence operating in the here and now that maintain psychological difficulty. For a contemporary exploration of psychodynamic theory applied to attachment-based dynamic psychotherapy, see Co-Creating Change (Frederickson, 2013).

Transference Transference is the term used to describe the unconscious patterns of relating manifesting within the therapy room from the patient towards the therapist, based on some form of identification with past relationships, often primary attachment figures. This does not mean that a person walks into the therapy room and immediately sees the therapist as their mother, father, or grandparent, although the identification can sometimes be explicit, typically it is much less concrete. The way a person approaches an intimate relationship or emotionally charged encounter can mobilise strong feelings based on their early experiences leading to anxiety and the use of defences as their attachment patterns become activated. Essentially, transference is a form of unconscious remembering from the past, being ‘transferred’ towards the patient’s ‘object’ in the here and now, in this case, the therapist.

Countertransference Countertransference (the response from the therapist to the patient) is what is being mobilised within the therapist based on what the therapist is thinking, feeling, and interpreting about what the patient is saying and doing in the therapy room. If the therapist is not careful, has low self-awareness or their response is not thought about, there is a potential that the therapist may be drawn into problematic dynamic patterns that are being unconsciously elicited by the patient (and vice versa).

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For example, if a patient has experienced particularly critical or emotionally neglectful caregivers, they might approach the therapeutic relationship with the expectation that they’re going to be criticised or minimised, or the therapist won’t care for them. They might then become anxious giving rise to their defence mechanisms of vagueness (general nonspecific descriptions that create distance in the relationship), intellectualising (distancing by engaging at a purely cognitive level), or compliance (agreeing and complying with everything that the therapist is suggesting, to avoid interpersonal conflict). Potentially, we may see the opposite depending on the processes of the patient, for example, attacking the therapist’s credentials and competency, arriving late and demanding additional time. If the therapist has also encountered critical and neglectful early experiences they may respond unconsciously and less objectively with distance, passivity, or attack, unless they have a good awareness of their own processes and tendencies. Psychodynamic psychotherapists and counsellors have to undertake extensive personal therapy throughout their training to understand their own patterns in relationships and defences in order to work safely and effectively within a transference relationship, particularly how this is addressed and discussed with a patient. Essentially, transference and countertransference are not simply a tennis ball transaction between the patient and the therapist, there is typically another past person (object) by way of primary attachment figures that are metaphorically present within the therapy room; see Malan and Parker (1995), for a more comprehensive overview of the triangle of the person.

Case vignette: Jane I will now attempt to demonstrate the explicit differences between the low-intensity clinical method, high-intensity CBT, and relational psychotherapy, through the case of Jane (Box 8.1). BOX 8.1 Jane is a single woman in her early 30s and works for a large PR firm. She laughs a lot during conversations, particularly when her mother asks about her love life and usually says, “I’ve not found anyone who can live up to my standards yet!” She has always been a high achiever, top of her class academically, and a social butterfly, a “go-getter.” She has always suffered from anxiety but doesn’t tell anyone about it. She hides it by saying, “I’m so excited, I’m shaking!” Recently, she was put forward for promotion to be head of the department at her firm but came second place to her equally talented and qualified colleague who just beat her to the post. Jane is a self-described perfectionist,

spending hours going over her work. Jane did not think that her colleague had shown the same degree of effort over the years. Since she was turned down for the promotion, Jane has been more anxious each day and has slipped into a period of depression but has hidden this well from others, telling everyone “I’m fine, I feel great.” Jane is now struggling to get out of bed in the morning. She did not mention the recent problems at work when she spoke to her GP but had requested to start antidepressant medication due to “work-related stress” and was then referred to her local IAPT service. Jane attends her first assessment appointment and has already completed a risk assessment.

The following dialogue in Box 8.2 represents the first section of a fictitious therapy session involving Jane and a therapist using an ethical low-intensity relationship whilst working within the limits of low-intensity intervention. The narrative is loosely based on Bennett-Levy et al. (2010). The following dialogue in Box 8.3 demonstrates how an ethical low-intensity relationship can still be maintained, despite clinical drift. The therapist maintains an appropriate therapeutic alliance but drifts by using a high-intensity CBT downward arrow intervention to dig down into core beliefs. The narrative is loosely based on Kennerley et al. (2017). One of the most common concerns that I hear when supervising low-intensity practitioners is that the term ‘therapeutic relationship’ draws up connotations of drift into counselling and psychotherapy. However, there are fundamental differences between a human-to-human relationship at low intensity and working relationally as an intervention with patients. The latter is where the reliance on the relationship is to bring about change as the main therapeutic tool. For example, an LICBT approach would use technical change interventions (diaries, information sheets, and written materials) as the main tools of intervention, and the relationship or ‘alliance’ is the way we engage with our patients in a human, here and now way. By contrast, therapeutic approaches that primarily work in the relationship, typically deliver their interventions through the relationship. Box 8.4 demonstrates what the final part of Jane’s appointment might look like if a therapist began to work relationally within a transference relationship. For low-intensity practitioners, this would be a very high level of unethical relational and clinical drift. For patients who enter psychodynamic therapy with trained or in-training therapists, there is an in-depth assessment process to ensure that the patient can provide consent to work in this way. Without the required

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BOX 8.2 Th: Can you tell me in your own words, what the main problem is that you would like me to help you with today? Jane: I guess I don’t really need your help as such, I just need some tips to get rid of this annoying anxiety I’ve been getting recently. Th: You’ve noticed that you have been bothered by anxiety a lot lately? Can you tell me a bit more about what happens when you are anxious? Jane: It just happens out of nowhere, my heart races, I get a dry mouth and start shaking, feel like I can’t breathe and stumble over my words. It’s so darn annoying! Th: It sounds like it really bothers you, Jane. Do you notice any specific situations when it happens the most? Jane: There isn’t any pattern, I can’t really give you a specific scenario, I guess I just need some tips and tricks to make it stop. Th: Have you noticed the anxiety recently? Jane: Actually, yes I have. It’s been bothering me a lot today.

Th: Maybe we could have a look at this together using something we call the five-areas model? Jane: What’s a five-areas model? Th: It helps us to capture the physical sensations and feelings we get with anxiety in particular situations, including our thoughts and the things we do in response to them. It can help us to work out what might be maintaining the problem. Jane: I’m not sure how that will help me, but I will give it a go if you think it will work. [they complete a five-areas formulation on a situation that day, and the practitioner gives Jane psychological education on the role of avoidance in anxiety] Th: What are your thoughts on doing the five areas, Jane? Jane: Honestly, please don’t take this the wrong way, but it’s similar to the ABC method I got from the internet. This doesn’t tell me anything I don’t already know. I’ve read a lot of self-help books over the years.

BOX 8.3 Th: Maybe we could take a deeper look at some of these thoughts you’ve described? Jane: See, this is why I don’t do therapy. Nothing bad has happened to me in the past, if I could just get rid of this darn anxiety I would be fine! Th: This worrying thought you described here ‘what if I can’t stop the anxiety’, what would happen if you can’t stop it? Jane: Well, obviously I would lose my job! Th: And what happens if you lose your job, what then? Jane: I would be unemployed? Th: What would it mean to your life to be unemployed? Jane: I would never allow that to happen! Th: What would it mean to you to not work? Jane: I would be a screw-up like everyone else! Th: What would be the worst thing you can imagine happening if you were a screw-up like everyone else? Jane: Well, no one would want me? [crack in her voice] Th: Can you say more about that? Jane: [curt tone] Well, not that it really matters, but my dad left when I was very young and I’ve never seen him since, but, well, you know, his loss, I guess. Th: Your father left when you were young. How did that affect you? Jane: How did it affect me? [dismissive tone] I don’t really remember. I guess I questioned why he didn’t stay. His loss, I guess. Th: You questioned why he left?

Jane: [detached ambivalent tone]. My mother was wrapped up in her own stuff at the time, she could never really help me. When I was 5 years old, she started seeing John. He was something else. This one time, I must have been quite young, I fell over and cut my knee, I ran to my mother crying, but she was with John. He shouted at me to stop crying and said I had to clean it up myself. He said I didn’t care about mum, I didn’t know how to clean a cut by myself and I got blood all over her new towels. He beat my mother afterward, shouting at her, saying that I was ruining everything, he was a total asshole. Th: It sounds like John was very critical of you and your mother was dealing with some difficult things at the time. Jane: Yes, I guess so. She was too busy trying to please John though. She was scared he would leave her as dad did. John ruled the house. He used to tell me that I was lazy. I once told him he was an asshole, but I soon learned to choke that back, he would take it out on my mother otherwise. Th: How might that affect you in the here and now? Jane: I don’t know what you mean. Th: Our early experiences in life can form something that we call core beliefs … Jane: [interrupts] I do remember that now from my self-help books. None of that really impacts me now though, I dealt with it and I moved on, I read that rumination is bad for you anyway [smiling].

extensive training, supervision, and personal therapy, it could potentially open the door to significant harm to the patient. Essentially, this is the relationship that low-intensity practitioners do not do. The narrative is loosely based on Frederickson (2013). I would imagine that the way of working I have outlined in the latter part of the vignette is not at all what springs to mind when we think about low-intensity relationships. The point I’m labouring here is that working within a transference relationship based on past attachment patterns or object relations is the furthest away from the low-intensity practitioner

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BOX 8.4 Th: Do you notice any feelings of anxiety as you are talking to me right now? Jane: Actually no, I feel a lot better now thank you. Th: I wonder how you might perceive me as you try to tell me about your problem with anxiety? Jane: What do you mean, how do I perceive you? I don’t perceive you as anything! Th: [silence] Jane: I guess I just need to do more to help myself, but I’ll be okay, I feel better now I’ve got it off my chest, thank you for that, you’ve been very helpful [smiling]. Th: Perhaps I might not be interested in your problem with anxiety and you should go away and deal with this on your own. Jane: I … erm … oh! [curt tone] So you don’t want to help me, then? Th: You tell me that you have a problem with anxiety and when I ask you about your feelings of anxiety you tell me that you feel fine and don’t need my help. I wonder how you might perceive my intentions? Jane: [laughing] Well, that is interesting, I recently read in Psychology Monthly Magazine that the amygdala gets … . Th: [interrupts] You told me about how you suffered as a child, your father abandoned you, your mother dismissed your needs, and your stepfather criticised you, sending you away to deal with the cut on your knee, alone, when you were in pain. When I ask you about your problem with anxiety you dismiss it, telling me about self-books and your amygdala. Do you notice how that keeps happening? Jane: I guess. Th: You guess? Jane: It’s just difficult for me … to … I … [Jane stops speaking; she places her hand to her throat] Th: What do you notice about your body right now? Jane: Nothing! Th: There is nothing happening in your body right now? Janes: Well, I guess, I guess, my hands, they feel a bit shaky. Th: What’s happening with your throat? Jane: My throat? Well [swallows heavily], it’s gone tight and it feels a bit dry. Th: That’s anxiety. Do you notice it anywhere else in your body? Jane: I feel a bit sick. Th: When I ask about your anxiety, your hands shake, your throat tightens and goes dry and your stomach feels nauseous? Is that right? Jane: Yes. Th: That’s a sign that your anxiety is very high. Can you describe what is happening in your stomach? Jane: [long pause] It feels like it’s churning, a bit like butterflies, but sickly as well. Th: Anything else that you notice about your stomach? Jane: [long pause] It feels like it is tightening now, like little knots, and my arms, they feel really shaky now and [laughing], I can’t stop moving my legs.

Th: Your arms are shaking and you cannot stop moving your legs? Jane: Yes, I feel like I need to keep moving them. Th: It is perfectly okay to move them. How is your stomach now? Jane: [pauses] It actually feels okay now. Th: And your thoughts, do they seem clear or are they blank, or blurry? Jane: I think it’s just anxiety like you say. Th: Are your thoughts clear? Jane: Yes, I think so. I’ll be able to manage it from now on I am sure. Th: So when I show interest in your problem with anxiety, your anxiety rises, and then you tell me you are fine and that you do not need my help. Do you see how that keeps happening? [long silence, tears are filling Jane’s eyes and her face is contorted] Jane: [gathers herself] I’m sorry, I didn’t mean to offend you. Th: You have not offended me, but I am curious if you see that when I am interested in how you feel, you dismiss my attention and tell me that you do not need my help. Do you see that? Jane: I always do that, it’s not you, I do it with everyone [weeping] Th: So this is a pattern for you? Jane [Long silence, nodding] Th: That you might be criticised and told that you are lazy, sent away to deal with pain on your own? Jane: [crying and nodding] Th: And this is painful for you? Jane: [sobbing, head down] I just feel so guilty. Th: You think you are to blame for having painful feelings and asking for help? Jane: [nodding] Th: Do you think that is a problem for you? Jane: [pauses, gathers herself] I don’t know. Th: Perhaps it is not a problem for you? Jane: It is a problem; it has been a problem for a long time. Th: And would you like to explore this problem in more depth? Get to the bottom of where this is coming from? Jane: I do. Th: And you see how pushing me away when I ask you about your problem causes you high anxiety and painful feelings? Jane: I do [starting to weep] Th: What is it that you would most like my help with? Jane: [wiping tears from her eyes] I want to stop feeling worthless. Th: Of course, and it makes sense given what you have told me about your early life as to how you might have come to think that you are worthless. Can you help me to understand a clear example of where you have thought that you have no worth? Jane: [long pause, weeping] Th: [silence] Jane: I recently applied for a promotion at work and …



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role as it gets. Simply relating to a patient empathically at a human level is not clinical drift, but it can be therapeutic and a vital part of the work. As low-intensity practitioners, we do offer complex reflections in relation to the difficulties the person is experiencing in the here and now, but we do not link these back to early experiences in relationships or traumatic events. At least not in the sense that we might explicitly vocalise this to the patient or discuss defence mechanisms and object relations theory. We also need to acknowledge that many people approaching primary care services will have experienced historical trauma, but many patients do not have sufficient resources to forcibly lift a lid on deep emotions. Particularly for patients where the impact of trauma may not be fully known to them or revealed until you are many sessions in. What comes up as you progress through low-intensity sessions is often far from predictable. If we accidentally pop open a lid during a session, we have to have the skills to support the person to contain this. Once again, these are our interpersonal skills and are vitally important, particularly where patients may be presenting with significant risks. For example, how do we support someone where we suspect safeguarding concerns for them or their children? How do we encourage someone to feel able to speak about difficulties and challenges at home, if we are only offering a surface-level distanced relationship? If we discount or mute our own processes, we also mute the common factor skills that we share with other therapeutic approaches. Essentially, we risk dehumanising the people on both sides of the therapy space.

Navigating ethical relationships in low-intensity practice One way of navigating interpersonal relationships in low-intensity therapy that I have found personally useful is to draw on the interpersonal process in cognitive therapy (Safran and Segal, 1996). This model considers the thoughts and feelings that arise in the therapist based on what the patient is saying or doing, using the term ‘pull’. Or in other words, what are we being drawn into doing? The adapted example I have outlined in Fig. 8.3 is based on what I view as one of the most common challenges in low-intensity practice, the completion of out-of-session tasks. In this example, the patient appears at the surface to be blaming the low-intensity material, but what the patient is, in fact, doing here is raising a complaint about the low-intensity practitioner. It is the practitioner who has recommended the behavioural diary, and the patient is reporting that this has made them feel worse. Although the patient is not directly expressing their protest with the practitioner, the practitioner may quite naturally pick up on this and feel a little wounded. Unless we then compassionately and sensitively address this by clarifying what the patient is actually meaning, we risk missing an opportunity to work through and repair the rupture. If we fail to check our wing mirror and notice the splashes, swells, and waves in the mill pond, we may take home the wrong suitcase of stuff and wellbeing may be impacted for both the patient and the practitioner.

FIG. 8.3  Interpersonal process in CBT-based practice. (Adapted from Safran, J., Segal, Z.V., 1996. Interpersonal Process in Cognitive Therapy. Jason Aronson, Incorporated.)

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Exiting defensive practice Stepping back from defensive practice or rescue and using our interpersonal skills to repair a rupture in the relationship is not easy and takes experience and practice. It also means opening ourselves up to getting it wrong and then learning from what went wrong. Box 8.5 demonstrates how the aforementioned scenario might look using our interpersonal skills to step off the trajectory of defensive practice or rescue. Admittedly this is an idealised dialogue during a session with someone presenting with moderate depressive symptoms. As any low-intensity practitioner will know, sessions are rarely ideal, no presentation is the same, and more often than not building the therapeutic alliance can be messy.

BOX 8.5 Ada: I tried the BA diary you recommended, it made me feel worse, I don’t think this is helping me! Th: That’s really useful information, Ada. I’m glad you felt you were able to tell me that. Sometimes the patients I work with can feel frustrated with the workbooks. I’m wondering if you might also feel frustrated with me or with something that I am doing or not doing? Ada: Oh no, it’s not you, you have been brilliant and so helpful, I just don’t think this diary business is helping me at all. Th: This sounds really important to you, Ada. I’m curious to understand what the most important part of that is, for you. Ada: I don’t know what you mean. Th: What might be the main thing that doesn’t feel right for you? Ada: I just thought that these sessions would mean that I could talk about my problems rather than just writing things down. I prefer to talk to you about it, it makes me feel worse when you ask if I’ve done the diary every session. Th: So, the most important part of treatment for you is being able to speak to me about the problems you are facing, but you only feel better when you are talking to me, you then feel anxious knowing I will ask you about the diary, have I got that right? Ada: Yes, I also feel awful when I am on my own at home, I really don’t like writing down my daily activity on paper. Th: Why do you think that is? Ada: It just makes me feel more depressed seeing the things that I want to do but I can’t. I feel more worthless.

Th: That makes a lot of sense, Ada. What it sounds like you are saying is that by not completing the diary you avoid thinking about the impact depression is having in your life, but the sting in the tail is that it then brings up thoughts of worthlessness. Ada: Yes, that’s right. Th: But what I’m also hearing is that you only really feel better when you come to speak to me, but you sometimes think that I don’t want to help you. Have I got that right? Ada: [pauses] well now you put it like that, I guess that’s different isn’t it. Th: How is it different? Ada: I think I’m avoiding tackling my problems and hoping that you will say something in the session that makes them go away. Th: Again, really useful information. It’s important for us to remember that wanting to avoid feeling bad is very normal, why would we want to do something that makes us feel bad? But by avoiding thinking about the problem at home, it can lead to avoiding the opportunity to think about solutions together in our sessions. Ada: That actually makes a lot of sense when you put it like that Th: I think it’s really great that you feel able to talk to me about this. It helps me to understand what happens for you. This way we can talk together in our sessions about how we can help you to make changes at home so you can start to feel better outside of the sessions. Ada: I really want to be able to do that! Th: I really want to help you to do that too!

Again, this is an idealised dialogue but hopefully demonstrates using a rupture in the relationship to strengthen the alliance. However, it is not uncommon for people to start to verbalise concerns about not being able to manage alone, asking how many sessions they have left, or asking for a different approach. It may then be the case that stepping the person up to formal counselling or psychotherapy is more clinically relevant, but we cannot know this unless we have developed enough therapeutic alliance to explore this. Obviously, we need to be aware of the limitations in our modality, but an opportunity to repair a rupture in the relationship should never be dismissed or ignored. We should always encourage patients to correct us and provide accuracy, and we stand a much better chance of engagement this way. How we manage this will be a personal process of development in supervision and how each individual clinician will do this will depend on their individual style. I personally found that inviting the patient to clarify what is happening for them bought me a little bit of thinking space to check my wing mirror and notice the mill pond. Inviting our patients to be curious about what is important for them, trying not to take what they say personally, becoming defensive, or making emotional assumptions is (for me) a crucial element of any therapy, including low-intensity therapy.

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The relational dynamics of systems Another very important consideration for low-intensity practitioners to be aware of is the relational dynamics within teams and systems. These can not only impact our personal wellbeing but also affect the work that we do with our patients (Box 8.6).

BOX 8.6 In Obholzer and Roberts (2003) The unconscious at work: Individual and organisational stress in the human services, we are offered a comprehensive psychoanalytic perspective of anxiety and defence operating within healthcare teams, services, and wider healthcare systems. In the paper, Swimming in the waters of a sinking National Health Service, Malda-Castillo and Anderson (2021), we are offered

a considered analysis of staff group dynamics within NHS mental health services where strong emotions that can arise when working within pressurised and underfunded systems result in team defences. I would recommend both texts as further reading for those who are interested in professional team dynamics.

One of the common pressures within professional teams in psychological services, particularly where services have limited resources is the acceptance of patients for assessment based on the service entry criteria and threshold in terms of risk. Staff in IAPT services commonly blame secondary care services for not taking their patients who present with higher risk but do not meet the threshold for secondary care. Secondary care services also commonly blame IAPT services for not taking lower risk cases that they assess as being suitable for primary care. In between these services are the GPs struggling to manage risk with their patients who present with mental health problems and persist in trying to get their patients seen by whichever service will eventually accept them. IAPT and secondary care services then commonly blame the GPs for inappropriate referrals. Patients start being bounced around services undertaking multiple assessments like a hot potato. GPs and patients then become angry and blame IAPT and secondary care services. The whole relational dynamic is an interactive system of anxiety, anger, guilt, shame, and blame maintained by policy, procedure, and a lack of funding.

Relational challenges in the current IAPT system in England Sometimes low-intensity practitioners who Liz refers to as the free for all practitioner may have a tendency to rescue and accept patients during IAPT service assessment who are unlikely to benefit from IAPT services, simply because there are no alternative options, and this was sometimes the case for me as a newly qualified practitioner. Equally, manualised practitioners can often unnecessarily restrict patients following IAPT service assessments who are likely to benefit from an IAPT intervention but don’t quite fit on paper. What we have then are a lot of patients who are left with either insufficient intervention or no service provision and take to social media to protest against the poor treatment and service (or lack of) that they have received. Yet, low-intensity practitioners can often be impacted by the burden of responsibility for policing the frontline of the systemic gaps in mental health and social care (Binnie, 2015; Westwood et al., 2017). The current systems also hold the potential for the development of cynicism towards patients as a result of such pressure (Rizq, 2012; Steel et al., 2015). Clinician burnout can also negatively impact patient outcomes, and where low-intensity practitioners work in sustained stressful conditions, may also be likely to experience feelings of depersonalisation, leading to lower empathy expression (Delgadillo et al., 2018). Subsequently, the reduced therapeutic alliance may then impact clinical decision-making, further increasing the likelihood of problems for the patient. The ideal of the IAPT model is published in guidance by the national team, but the national team has their hands tied in terms of local commissioning and individual service operation. Yet, if individual services do not meet the national standards (access, outcomes, and waiting times), they risk losing their commissioning and/or being performance managed by the national IAPT team at NHS England. In order to meet the national standards and deliver on their local commissioning targets, service managers can become reactive to remedy the shortfall in their quantitative data reporting to avoid financial penalty (payment by results) or further scrutiny. The pressure to perform then requires a solution to quickly increase throughput to achieve access and outcome targets. Inevitably, the problem is passed to the staff on the frontline who provide the majority of the throughput in services due to the short-term nature of their work. Low-intensity practitioners then burnout or leave, further compounding the problem with pressure for access and outcome targets.

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When the cracks appear and staff, patients, and seasoned academics start making public criticisms, there is then a distancing of IAPT ‘the programme’ from individual IAPT ‘services’ within the public discourse. It makes sense that services that operate well under the IAPT programme will wish to distance themselves to defend against the broad assumptions that they are equally ‘bad’ based on the activity of other services that are struggling. However, separating the relationship between the IAPT programme and IAPT services is problematic.

Understanding ruptures in systems: Whose anxiety is this? The national IAPT guidance for services operating under the IAPT programme (see, the National Collaborating Centre for Mental Health, 2021) is admirable, and for the most part, outlines an inclusive offer of short-term counselling and psychotherapy involving a range of modalities. However, there also has to be operational accountability for individual IAPT services and a minimum standard to safeguard staff and patients, based on the best available evidence. This is where the ruptures begin. The ideal of the model enters a competitive marketplace with various NHS, third sector, and private providers bidding for local service tender. Local services often lack the resources to fight for their place in the bidding wars, sometimes resulting in overpromising what they can reasonably deliver without there being an inevitable impact on their staff and patients. Once difficulties arise around access and outcome targets, those services can then begin the process of attempting to manage failings in clinical care with data spreadsheets and IT systems to paste over the cracks. What this does tend to achieve is typically advantageous reporting of achieved key performance indicators (KPIs) to sustain commissioning but does not highlight the inevitable costs involved for both patients and staff, at a human level. This is not an attempt to lay the entirety of the blame at the commissioner’s door, they can only work with the money they have, and there are many services in need beyond that of their local IAPT provision. We also need to acknowledge that the majority of IAPT service managers are very likely experienced and caring individuals who are simply trying to cope as best they can to support high-volume clinical care with low-volume resources. It is also true that there are IAPT services in England that operate well and no doubt there will be staff who work in those services who barely recognise the narrative offered here. But, there are also many services where poor staff wellbeing is the norm, and it is not simply a handful and is not isolated geographically. We can take to social media or speak to low-intensity practitioners at any national event to hear about the very large problem with staff wellbeing in IAPT services. Adopting a “not all” veneer to systemic problems simply sweeps them under the corporate rug and locates the problem with individuals. However, we cannot simply separate and lay individual blame entirely on those services who are struggling, when everyone involved in the entire system as a collective national IAPT programme is, to a degree, responsible through the parts they individually play. The whole system becomes ruptured. Of course, very few people find it easy to open themselves up to criticism or feel brave enough to stand up in isolation and fight against the actions of their wider group or management teams. It makes sense then that pointing out flaws and deficits within stressed systems will inevitably elicit a strong response in both the person making the criticism and those who are responding to it. We then maintain a destructive cycle of fear, anger, and sadness being sublimated through tables, charts, spreadsheets, and staff wellbeing activities, maintaining restricted patient access, poor clinical outcomes, and staff burnout. The whole system becomes sick. As we know from family systems (see Dallos and Draper, 2000), when one part of the system is showing signs of difficulty, it is typically responding to other problems appearing elsewhere in the system. Without objective analysis of the system as a whole, there is a risk of jumping to conclusions as to the source of the problem based on our personal biases and tendency to use defences to ease our own anxiety and fear of criticism. An example here in the context of family therapy, might be where parents seek support due to their child’s behaviour at home, and several sessions in; it transpires that the arguments expressed within the parents’ relationship is creating anxiety in the child and the child is acting out in response. The child acting out creates further anxiety and arguments in the parents’ relationship, but the parents continue to blame each other or the child, maintaining the anxiety and behaviour of the child. Until we are able to see the problem as a system, we are at risk of locating the source of the problem solely within the child, or solely in one or both of the parents, the family problem is maintained, and the rupture remains unrepaired. In order for IAPT services to contain their anxiety, they must satisfy the pressure to achieve the targets needed to provide evidence to their commissioners. Services then need to increase the demands on their frontline staff to achieve the targets and produce the evidence. The frontline staff then become anxious and need to perform in order to achieve the targets and demands of the service, who need to achieve the targets and demands of commissioners. The commissioners need to achieve the targets and demands of distributing funds to the wider healthcare provision locally, in order to meet the demands and targets from the central government. The entire system is anxious.



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We then have anxious patients waiting to enter treatment with an anxious therapist, working within anxious and highly pressurised systems. Ironically, the patient whom the whole system, service, and therapists are anxious about is the person with the least power, choice, or control over the service and type of therapy they receive for their anxiety, based on the systemic pressure to achieve the targets about them being anxious.

Navigating relational boundaries in systems So why is this important to know as a low-intensity practitioner and what can we do about it if it is a systemic problem? From my personal perspective I think it is very important for low-intensity practitioners to be aware, or at the very least remind themselves when they are feeling the pressure of their role that they are quite literally working at the outlet of considerable pressure within systems. As I also outlined earlier in the chapter, all humans experience attachment patterns and defence mechanisms when experiencing pressurised or emotionally charged encounters. Whether you are psychologically healthy or not, the intense relationships we can experience within the workplace, with patients, within teams, and the system as a whole will undoubtedly activate our patterns of relating, defences, and coping. This is also perfectly normal. But unless we are able to check in with the mill pond and our wing mirror we may mistake the distress, emotions, and defences within systems as our own and take home the wrong suitcase of stuff. The splashes, swells, and waves that we experience at work may also partly belong to us through our experiences and identifications with others. Unless we notice it and it is thought about, we risk responding in ways that may impact our own wellbeing and that of our patients. We may also act defensively in the workplace, verbally attacking our services. We might also see splitting (explored in more depth in Chapter 9, Reflecting on Interpersonal Practice), essentially, extreme polarised positions around low-intensity therapy being “completely brilliant and useful for everyone” or “utterly rubbish, pointless, and useless” with little room for integrated thinking about the strengths and limitations of the model. Alternatively, we may overstretch our personal resources, offering to cover shifts, and increasing our caseloads in an attempt to rescue our management teams and relieve their distress. By contrast, we may devalue ourselves, silence and minimise our own needs through quiet, compliant adherence to unreasonable service demands. As someone who has a natural tendency towards rescue, I regularly felt the need to increase my workload in response to the plethora of emails appealing for help from service managers. Mostly, this resulted in thanks and gratitude but was not necessarily conducive to healthy work wellbeing. It is far more important that we check our mill pond and wing mirror and begin to set our own limits and boundaries, just as we do with our patients. These help to protect both ourselves and our patients from harmful team dynamics and defensive practices that can appear across the system during times of pressure and difficulty. Sometimes our boundaries are reasonable but are consistently being violated by systems, being pressured to offer more than we can safely do. We may then need to consider how we can be supported with this. In English NHS services we have the option to contact a Freedom to Speak Up Guardian. This is someone who can provide impartial advice for people who feel unable to address concerns with their immediate management teams or systems. For some low-intensity practitioners, it may be the case that they search for an employer where the dynamics are healthier, to protect their own wellbeing. This is covered in more depth in Chapter 7, Staff Wellbeing.

The importance of empathic and compassionate relationships Low-intensity psychological practitioners share common human interpersonal skills with most other therapeutic modalities. This is our capacity for self-reflection, empathy, and compassion. This isn’t simply about sitting across from a patient making concerned facial expressions and repeating what the patient is saying. True empathy is hard and, in many cases, uncomfortable. Empathy is being able to walk for a moment in another person’s shoes, despite this being unrecognisable or too recognisable in our own values, beliefs, and experiences. Empathy is when your patient tells you that they found Google more helpful than your session but you are able to sit with the irritation and shame and still think about why the person feels the need to distance themselves from you. What can be more difficult is being empathic when noticing your own personal distress, for example, when someone drives into the parking space that you have been waiting patiently for and then starts shouting at you when you raise a complaint. What unmet needs might this person be demonstrating? How might they be feeling underneath their rage? Empathy is also about being able to think and care about the pressure and anxieties manifesting in your manager when the service is at risk of failing its targets. Checking your mill pond and wing mirror, being able to pause, notice the swells and waves, avoiding becoming overly defensive and firing off an angry email, or the opposite where you offer rescue,

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­ orking beyond your available resources. The middle ground is messy, requires integration and compromise, but is esw sential for wellbeing. These skills can take considerable effort and time to develop, and the degree to which someone may need to be supported in doing this may extend beyond the workplace, in some cases, into personal therapy, regardless of their modality. Most important is the empathic relationship we have with ourselves, or ‘self-compassion’. This is the ability to notice our mill pond, check our wing mirror, and learn to better understand our own needs, recognising the impact that the pressures of clinical work and pressurised systems have on our ability to sustain ourselves. Being able to afford yourself the graces that you might afford to others, taking time away if you are ill, speaking out if you are upset. Self-compassion is also learning to find your voice if you have been silenced. Ultimately, it is being able to notice and embrace healthy interpersonal relationships, being able to check your mill pond and wing mirror where relationships may be less healthy and asking yourself, whose emotions and experiences are involved?

Key messages ● ●

●

●

Safe and ethical low-intensity therapy relationships require the same boundaries as any other therapeutic modality. Self-awareness within the therapeutic alliance is as important in low-intensity work as it is in any other psychotherapeutic modality. Therapeutic drift is common and can be subtle, often multidirectional and nearly always intentional, but can lead to unintentional harm if not addressed. Relationships within wider teams and services can lead to systemic problems and harm. Encouraging compassionate systems and empathy towards yourself and others is crucial for sustaining wellbeing within teams.

References Amos, R., Morris, L., Mansell, W., Edge, D., 2019. Clients’ experiences of one to one low intensity interventions for common mental health problems: an interpretative phenomenological analysis. Psychol. Psychother. Theory Res. Pract. 92 (4), 565–583. Barkham, M., Saxon, D., Hardy, G.E., Bradburn, M., Galloway, D., Wickramasekera, N., et al., 2021. Person-centred experiential therapy versus cognitive behavioural therapy delivered in the English Improving Access to Psychological Therapies service for the treatment of moderate or severe depression (PRaCTICED): a pragmatic, randomised, non-inferiority trial. Lancet Psychiatry 8 (6), 487–499. Bennett-Levy, J., Richards, D., Farrand, P., Christensen, H., Griffiths, K. (Eds.), 2010. Oxford Guide to Low Intensity CBT Interventions. Oxford University Press. Binnie, J., 2015. Do you want therapy with that? A critical account of working within IAPT. Ment. Health Rev. J. 20 (2), 79–83. Bowlby, J., 1978. Attachment theory and its therapeutic implications. Adolesc. Psychiatry 6, 5–33. British Association of Counselling and Psychotherapy, 2016. Ethical Framework for the Counselling Professions. https://www.bacp.co.uk. Cashdan, S., 1988. Object Relations Therapy: Using the Relationship. WW Norton & Co. Dallos, R., Draper, R., 2000. An Introduction to Family Therapy: Systemic Theory and Practice. Open University Press. Delgadillo, J., Saxon, D., Barkham, M., 2018. Associations between therapists' occupational burnout and their patients' depression and anxiety treatment outcomes. Depress. Anxiety 35 (9), 844–850. Dew, Reimer, 2003. Essential Research Findings in Counselling and Psychotherapy: The Facts Are Friendly. Sage (cited in Cooper, M. (2008)). Frederickson, J., 2013. Co-Creating Change. Seven Leaves Press. Freud, S., 1894/2014. The Neuro-Psychoses of Defence. Read Books. Ghaemian, A., Ghomi, M., Wrightman, M., Ellis-Nee, C., 2020. Therapy discontinuation in a primary care psychological service: why patients drop out. Cogn. Behav. Ther. 13, E25. Johns, R.G., Barkham, M., Kellett, S., Saxon, D., 2019. A systematic review of therapist effects: a critical narrative update and refinement to review. Clin. Psychol. Rev. 67, 78–93. Kennerley, H., Kirk, J., Westbrook, D., 2017. An Introduction to Cognitive Behaviour Therapy: Skills and Applications, third ed. Sage Publishing. Malan, D., Parker, L., 1995. Individual Psychotherapy and the Science of Psychodynamics. CRC Press. Malda-Castillo, J., Anderson, D., 2021. Swimming in the waters of a sinking National Health Service (NHS): a group analytic perspective. Group Anal. 55 (1), 3–18. Marshall, D., Quinn, C., Child, S., Shenton, D., Pooler, J., Forber, S., Byng, R., 2016. What IAPT services can learn from those who do not attend. J. Ment. Health 25 (5), 410–415. National Collaborating Centre for Mental Health, 2021. The Improving Access to Psychological Therapies Manual. Available from: https://www.england. nhs.uk/wp-content/uploads/2018/06/the-iapt-manual-v5.pdf. Obholzer, A., Roberts, V.Z. (Eds.), 2003. The Unconscious at Work: Individual and Organizational Stress in the Human Services. Routledge. Pihlaja, S., Stenberg, J.H., Joutsenniemi, K., Mehik, H., Ritola, V., Joffe, G., 2018. Therapeutic alliance in guided internet therapy programs for depression and anxiety disorders—a systematic review. Internet Interv. 11, 1–10.



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Pybis, J., Saxon, D., Hill, A., Barkham, M., 2017. The comparative effectiveness and efficiency of cognitive behaviour therapy and generic counselling in the treatment of depression: evidence from the 2nd UK National Audit of psychological therapies. BMC Psychiatry 17 (1), 1–13. Rizq, R., 2012. The perversion of care: psychological therapies in a time of IAPT. Psychodyn. Pract. 18 (1), 7–24. Safran, J., Segal, Z.V., 1996. Interpersonal Process in Cognitive Therapy. Jason Aronson, Incorporated. Saxon, D., Firth, N., Barkham, M., 2017. The relationship between therapist effects and therapy delivery factors: therapy modality, dosage, and noncompletion. Admin. Pol. Ment. Health 44 (5), 705–715. Schore, A.N., 2017. Modern attachment theory. In: Gold, S.N. (Ed.), APA Handbooks in Psychology®. APA Handbook of Trauma Psychology: Foundations in Knowledge. American Psychological Association, pp. 389–406. Schore, A.N., 2019. The Development of the Unconscious Mind (Norton Series on Interpersonal Neurobiology). WW Norton & Company. Steel, C., Macdonald, J., Schröder, T., Mellor-Clark, J., 2015. Exhausted but not cynical: burnout in therapists working within Improving Access to Psychological Therapy Services. J. Ment. Health 24 (1), 33–37. Turner, J., Brown, J.C., Carpenter, D.T., 2018. Telephone‐based CBT and the therapeutic relationship: the views and experiences of IAPT practitioners in a low‐intensity service. J. Psychiatr. Ment. Health Nurs. 25 (5–6), 285–296. Waller, G., Turner, H., 2016. Therapist drift redux: why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track. Behav. Res. Ther. 77, 129–137. Wampold, B.E., Imel, Z.E., 2015. The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work. Routledge. Wampold, B.E., Minami, T., Baskin, T.W., Tierney, S.C., 2002. A meta-(re) analysis of the effects of cognitive therapy versus ‘other therapies’ for depression. J. Affect. Disord. 68 (2–3), 159–165. Westwood, S., Morison, L., Allt, J., Holmes, N., 2017. Predictors of emotional exhaustion, disengagement and burnout among improving access to psychological therapies (IAPT) practitioners. J. Ment. Health 26 (2), 172–179. Yalom, I.D., Leszcz, M., 2020. The Theory and Practice of Group Psychotherapy. Basic Books.

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Chapter 9

Reflecting on interpersonal practice James Spiers

Key aims of this chapter ● ● ● ●

To draw practitioner awareness to problematic interpersonal processes common in low-intensity practice. To consider the impact of low therapeutic alliance on treatment efficacy and safety. To support supervision and self-reflective practice for low-intensity practitioners. To support the development of interpersonal skills beyond the training year.

Personal motivation for LICBT training I will open this chapter with a frank and honest disclosure. I am someone who trained as a low-intensity practitioner with the sole aim of it being a ‘stepping stone’ to an applied psychology doctorate. Stepping stone is an urban term commonly used in IAPT services to describe a large number of people who apply to NHS-funded postgraduate training programmes to gain experience to bolster their application forms for either CBT or practitioner psychologist training courses. I am, in part, typical of this group, yet also atypical in that I have retained strong links to low-intensity practice since. Prior to applying to the IAPT programme as a trainee psychological wellbeing practitioner (PWP), I had read forums where disgruntled staff were posting about therapy scripts and empathy dots (to remind you to display empathy). I watched a series of practitioner training videos on the Reach Out website, to help me to prepare for the role-play element of the interview. The videos made me squint so much that I could only bear them in 10-min bursts. I had heard horror stories from former IAPT therapists about the workload, the targets, and the “conveyor-belt” approach to therapy with PWPs being used as “battering rams” to hold back the pressures on the waiting list for high-intensity therapy. Having applied for numerous assistant psychologist (AP) posts without success, AP posts being notoriously hard to obtain, often on temporary or honorary contracts, the trainee PWP role afforded me the opportunity to gain valuable clinical experience with a higher salary and a stable employment contract once qualified. As will be the case for people who opt for a strategic approach to their career, there will always be individual context and personal circumstance that influence decisions to accept an offer from a training course, particularly salaried posts such as the low-intensity practitioner training. For me, despite very obvious early signs that I was going to be a clunky fit to the programme, my thinking at the time was that it was simply a couple of years out of my life to gain clinical experience as a pit stop to the career that I wanted. The horror stories? Well, those were probably just people who couldn’t cope with the pressure. I was good under pressure; how hard could it be? Needless to say, it was hard, very hard, and applying for a job that had made my skin itch when reading about it, simply to facilitate an application for further training were not particularly harmonious conditions as a starting point for either me, the IAPT training programme, or the IAPT service I would be working in. It is important to point out here that whilst I am painting a pretty dismal picture of my personal values, it is quite normal (and healthy) for people to hold career ambition and equally common that they will need different experiences to achieve this. This can be said for most professions, including for people like Liz, currently an assistant professor, who have aspired to develop their longer term career in clinical teaching as their specialism. For psychological therapy training in the United Kingdom, getting onto a funded training route is also a highly competitive business. Reflecting back on my application stage to the IAPT programme, my aspiration was to become a psychologist. This was in part because I was interested in complex case work. Yet, there was also another part of me that idealised it. Somehow, it would stop the voice in my head telling me that I was not good enough, an imposter. For those who are reading this chapter as aspiring psychologists, the reality here (at least for me) is that going onto further training did not stop the voice of selfdoubt. It was actually personal psychotherapy that brought me to a place of being more comfortable within myself, albeit facilitated by the training course. Care in High Volume. https://doi.org/10.1016/B978-0-323-88492-1.00009-9 Copyright © 2023 Elsevier Inc. All rights reserved.

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Essentially, the start of my journey in IAPT began in a place of what Carl Rogers (1961/2012) referred to as incongruence, I did not wish to have a career as a low-intensity practitioner, and was in denial about the challenges of the training course, and already in a position of devaluing the low-intensity role. I thought that I would have to hide in plain sight, particularly during the training year. That was, until the first day at the University of Sheffield, where 52 trainees stood in a large circle around the room and were asked if their aspiration was for either CBT training or applied psychology, 31 of us stepped forward. Yet, it is during the more recent years of working across different tiers of the mental health system that I have come to truly appreciate the value of low-intensity psychological practice. Unique skill set is needed for creativity and adaptability, in addition to the exceptional resilience required to sustain someone in the role. The core skill set goes way beyond that of an ability to talk someone through a guided self-help manual. Many of the skills I acquired as a PWP such as collaborative problem formulation, goal identification, overcoming barriers to change, containing and focusing sessions, relaying complex theory and concepts in digestible, easy-to-understand terms have been incredibly valuable and have served me well as a robust platform to build on during further training. I am aware from both friends and colleagues that I was not alone as an aspiring psychotherapist or psychologist, in that I had approached the IAPT programme as the metaphorical Wizard of Oz, setting off on the yellow brick road in the hope of reaching an Emerald city, using the PWP role to pave the way underfoot. It wasn’t until I started training as a psychologist that I began to make better sense of my experiences as a low-intensity practitioner. I began to pose questions. What was it about the relatively static policies and protocols of IAPT services that could send me spiralling to the roof with anger, accusing the programme of being useless, to being protective of it when the service I was working in was coming under fire for failing its targets? What was it about my own needs that would generate my continuous citing of the ubiquitous mantra of low-intensity work being “a sticking plaster,” equating it to the therapeutic equivalent of McDonald’s, yet readily engaging in supervisor training and attempting to support low-intensity practitioners to develop their own practice? Essentially, these were subtle indicators of the implicit processes of idealising and devaluing.

The seesaw of valuing Idealising and devaluing is what psychoanalysts and psychodynamic psychotherapists might refer to in a clinical context as a protective process of ‘splitting’, a defence mechanism against strong or painful feelings in the face of interpersonal stimuli. Splitting forms in early childhood where a child or infant might struggle to hold contradictory thoughts about their caregiver in their mind. For example, a good ‘part’, “mummy likes my drawings, she gave me cuddles afterwards, mummy is good,” versus a bad ‘part’, “I drew a picture on the living room wall for mummy, she screamed at me and scared me, mummy is bad.” To defend against the complex emotions and potential anxiety manifesting as a result of the conflict, the child learns to separate the ‘parts’ and the perception of the mother becomes polarised as either all good or all bad. That is, until the child develops and learns to integrate the parts, viewing the mother more realistically as capable of being both good and bad, see Klein (1932, 1935) for a more comprehensive reading on the concept. For those where their early development is interrupted or stalled due to separation or traumatic events, being in contact with another person as an adult may potentially stir similar strong complex emotions leading to distorted perceptions of the other. For example, meeting a potential friend or colleague that may be kind and helpful, but where there is an identification (based on their early relationships) that elicits a perceived risk, such as personal flaws being seen, the potential of criticism, neglect, rejection, judgement, or humiliation. This gives rise to complex emotions, leading to anxiety and the person employs idealising (all good) or devaluing (all bad) to either themselves or the other/s, as a way of managing this. Common manifestations of idealising in a clinical context might be where (in high intensity therapy) we might ask the patient “what was your childhood like?” Rather than stating what is more generally realistic of life, “it was a mix of good times and bad times,” the suppressed anxiety-provoking elements are outside of awareness, “I had a perfect childhood.” This is not to suggest that everyone who idealises has experienced severe trauma in early life, but the experiences it stems from are not something that would be explored in LICBT intervention. Evidencing why, as low-intensity practitioners, we do not go digging into the patient’s past, even with people who at the surface appear to have mild problems. Often, what is hidden from awareness can be painful to acknowledge (hence it is defended against), this can also be the case for practitioners. Either way, we would need consent and adequate training to explore this. Idealising and devaluing in some form or another is common, and whilst this will vary depending on the early experiences, personality organisation and belief system of the person, ranging from sales executives, “my product is the best in the world,” to shifting from one side of the split to the other when our attachment system is under pressure, e.g., when “ten



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years of a perfect marriage and two perfect children” suffers an unexpected jolt through infidelity, relegating the “perfect” husband to garbage, “you have always been a terrible husband and you are useless in bed,” to more extreme, marked, and problematic patterns seen in clinical populations who have experienced considerable trauma in their early life. This is by no means an attempt to suggest that people applying for low-intensity training have pathological problems in relationships, or traumatised attachments, nor trying to equate normal experiences with a clinical problem. Many of us are likely to have encountered devaluing to some degree during our early adolescent social development, navigating the often very painful (and normal) experiences of rejection in friendships and peer groups to avoid strong complex feelings such as anger, envy, jealousy, and love. Making generalised statements that lack objective factual balance, particularly when perceiving potential criticism or rejection from a group, we might have wanted to belong to, or have found to be of potential value to us, e.g., “I never wanted to be part of the science club anyway, they are all nerds, who wants to be associated with nerds!” Essentially, I am not referring to idealising and devaluing in a pathological context, what I am saying here is that when we are faced with situations that pressure our sense of self-image we can react and respond less objectively, becoming more black and white in our thinking. This can also present in ways that can be problematic to both ourselves and others when we are working in a professional clinical context. I will be drawing loosely on the concept of devaluing as a way of normalising but also more explicitly highlighting the often subtle, and outside-of-conscious awareness processes that I commonly experienced in low-intensity clinical practice and my professional interactions surrounding it. The ways in which we might idealise, placing ourselves, others, or our professional modality on a metaphorical pedestal, or using devaluing to place ourselves, others, or their professional modality in the rubbish bin. Of course, no one person or thing is perfect, nor without any value at all, including ourselves. It is true that some things in life may, or could be better in different contexts, but it is important that we can have room in our minds to consider what is both good and bad, a more balanced reflective position between the two extremes of the seesaw of valuing (Fig. 9.1). Trying to approach our interpersonal process in a way that we can start to learn to be more compassionate towards ourselves, noticing where we might be devaluing or overestimating our abilities, including in our relationships with patients, and also noticing where we might be kinder and more compassionate towards others, where we might be less objective in our critique. Through greater awareness of valuing and devaluing my hope here is that it can provide greater opportunities for reflective learning and growth.

FIG. 9.1  The seesaw of valuing.

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Relevance to low-intensity practice So why is all this relevant to low-intensity psychological therapy? If we momentarily park the terminology from psychoanalytic theory, thinking more pragmatically about the surface level interventions and the different styles of relating experienced in low intensity work, these are the interactions where, as a supervisor, you might be coming away from watching or listening to a recording of a supervisee with a feeling about the interaction that you can’t quite objectively put into words on the competency marking grid. There may just be something about the interaction that makes you uncomfortable, or more explicit, where you are left with complex and challenging emotions afterward. An example here might be where we are discussing challenging feedback in clinical supervision with the supervisee (Box 9.1): Box 9.1 Nasreen: I’ve marked your treatment recording, Paul. There were some places where you did really well, but I had some concerns about the accuracy of what you said to the patient about the autonomic nervous system. I wonder if we can discuss that? Paul: I totally get what you mean, I gave a terrible explanation to the patient (devaluing—self) I am so lucky to have you as my supervisor, you always know how I can improve, you are the best supervisor I have ever had (idealising—other).

We might also see this happen in reverse, where someone’s process is to devalue the other (Box 9.2): Box 9.2 Nasreen: I’ve marked your treatment recording, Paul. There were some places where you did really well, but I had some concerns about the accuracy of what you said to the patient about the autonomic nervous system. I wonder if we can discuss that? Paul: Really? I’m pretty sure that explanation was similar to the one I wrote about when I received a distinction in my master’s degree (idealising—self). The last supervisor I had also agreed with my take on it, they had a master’s in neuroscience too (devaluing the current supervisor).

Whilst this is a more explicit example, idealising and devaluing is not as uncommon as we might imagine in either clinical or professional interactions. I am particularly alert to explicit idealising, being placed on a pedestal by either a patient or supervisee. This is a precarious position to hold, and whilst it can sometimes feel very nice, it is also unrealistic. The problem is that should I fall off that pedestal through needing to directly challenge, address problems, get something wrong, or make a mistake, then there is a risk, depending on the process of the individual, of quickly shifting to the opposite position from the pedestal to the rubbish bin. Not conducive to a healthy working alliance. When I become aware of explicit devaluing (often passive aggressive), this might indicate to me that the person (whether patient or supervisee) may likely be perceiving me as threatening in some way, again leading to potential problems in developing a strong working relationship. It also poses potential problems for the patient or supervisee too. If someone is employing either devaluing to themselves or to others, they are potentially limiting what could be more thought about in terms of the usefulness and value they could receive from the other, or what they themselves could offer that is useful and of value to the other. Paying particular attention to devaluing gives us an opportunity to notice and respond with compassion, or address and discuss what might be happening within the relationship that is getting in the way. Obviously, we cannot attribute all positive and negative comments as idealising and devaluing, we obviously have to live a normal life alongside psychological concepts. It is quite possible that we have unintentionally said something off hand that has offended the other person, we may have inaccurate information about neuroscience, be unaware of our own tendency to idealise and devalue others, at times. The benefit of awareness is that if we can become better at spotting where we might be moving in either direction away from the healthy middle of the seesaw of valuing in our clinical interactions, where we are better able to reflect, more able to integrate, and hold a healthier balanced position, we are more likely to be able to work through relationship ruptures with our patients, our colleagues, and with ourselves.

Devaluing between groups In professional teams and interdisciplinary workplace contexts, we might think more readily of these processes in terms of social comparison (Festinger, 1954) or social identity (Tajfel and Turner, 1979). Essentially, a common human tendency

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is to associate our sense of esteem, purpose, and value with our sense of our identity when belonging to groups. In professional psychological services, part of our group identity at work might be thought about as our clinical role, e.g., “I am a”: PWP, CBT therapist, counsellor, psychotherapist, or psychologist. Everyone attempting to achieve similar aims (helping patients to improve their symptoms of distress), but each coming from a different theoretical position, different training, each categorised, scaled in terms of the complexity of patient presentations, often differing salary bands, and in many cases, perceived status. It is also common to hear devaluing statements between the psychological disciplines, we can simply scroll through Twitter to see this in action on a daily basis, both Liz and I also commonly witnessed similar narratives around the office during our time in IAPT (Box 9.3):

Box 9.3 PWP: “Exactly what do psychologists do anyway? They literally sit in meetings all day, making vague statements about patients, do they ever actually see any patients?” CBT therapist: “If someone just wants to simply chat then you might as well step them to counselling.” Counsellor: “Only highly defensive people are attracted to CBT training.” Psychologist (to a PWP): “You realise that low-intensity therapy is not actually a thing!”

Anxiety around patient engagement: The training year Looking back on this some years later and having witnessed many trainees navigating their way through the low-intensity training year, “robotic” and “scripted” approaches to clinical work were a common complaint by around half of the cohorts, which Liz refers to as the ‘manualised practitioner’. My personal take on this is that this mostly stems from early-stage career practitioners who are anxious about not fitting with a professional group and fear getting it wrong, basing their ability to undertake a low-intensity clinical session on comparing what they see and hear others doing, whether this is watching demonstration videos or large clinical practice groups, called ‘fishbowls’ (a group of trainees sitting around watching other trainees interact, taking turns). Once they start working in their services undertaking supervised clinical work with patients, here, they learn from their supervisors, fellow trainees, and other qualified staff within the service. If you work in a service where your peers and leadership team are mostly manualised practitioners, then inevitably the scripted and manualised sounding approach to the work gets passed down like a family heirloom. Yet, what I also commonly witnessed were practitioners who would ‘perform’ in a more manualised and scripted way when being overheard or potentially scrutinised by others (e.g. in an open office or during clinical recordings for university submission), but would be less scripted and more natural when in one to one contact during sessions outside of the eyes and ears of others. What trainee practitioners often fail to grasp is that the scripts and crib sheets are simply a guide rope, reminders and prompts to ensure that they cover vital elements of the session conducive to change, not to be read out word for word as if you are undertaking a safety demonstration on a Boeing 737 about to take off. Whilst I was never someone to follow scripts or crib sheets, I did hold the perception, common with trainee practitioners, that because patients would often associate psychological therapy with counselling (more often than not due to not understanding the differences between the modalities), that what I could offer (LICBT) would neither meet their expectations or be sufficient to help them with their problem. Reflecting back on this now, this was a projection onto the patient (a less objective generalised assumption) of my own personal thoughts and beliefs about LICBT, ‘what use is this to the patient?’ As well as the view of myself, ‘therefore, what use am I to the patient?’ Outside of clinical recordings for university purposes, the temptation was strong to move from the triad relationship between the patient, self-help material, and my own clinical input, to drifting towards a dyad, with the LICBT workbook sitting in the metaphorical trash can. The degree of clinical drift would also fluctuate depending on my interactions with different patients. For example, with patients who would use devaluing as a defensive strategy I could become tangled up in that process, feeling anxious in sessions, giving overly complicated explanations, high intensity CBT worksheets as homework downloaded from the CCI website, and detailed technical explanations of the fight or flight, using intellectualising as a defence. With patients who leaned more towards idealising, I could often drift into what became more of a purely listening, pseudo counselling session, where I was practically pinned, muted to my seat, for fear of interrupting or upsetting the person. I would also regularly run over session time, particularly with patients who presented with strong expressions of helplessness. I would also complain relentlessly about the average of four to six sessions being inadequate and insufficient to meet need, and felt that patients were being “short changed,” again a common narrative in low intensity practice. Whilst

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at the time of training as a PWP, I had no formal awareness around interpersonal dynamics, and whilst these also included marked and generalised patterns for me personally, they were also outside of my conscious awareness. Obviously we cannot reasonably or ethically train low-intensity practitioners to work relationally with patients, or mandate that they all have years of personal psychotherapy during training (albeit that this is the case for many of the non-IAPT psychotherapy training courses), but this also takes years of training, practice, and supervision. What we can do is start to equip low-intensity practitioners to learn to monitor and notice their own processes in the here and now.

Therapeutic working alliance Different therapy modalities conceptualise the therapeutic/working alliance in various ways. The main overlapping concepts applicable to low-intensity therapy are the common factor skills (see Roth and Pilling, 2008), that of attunement between the patient and the practitioner. In other words, both the patient and practitioner are on the same page and working towards a common aim. Typically, signs of a good working alliance in low-intensity practice are where we might see the patient engaged with the basic techniques and are able to relay to you as a practitioner how the technique applies to their life, and more importantly, how it is being applied (or not) to the reality of their lives outside of the session. It is also important to note that a healthy interpersonal alliance is not necessarily consistently harmonious and cheerful, rarely do we encounter effective interpersonal skills in any therapeutic modality where the patient and the practitioner consistently engage in a pleasant exchange at every step of the way. A true therapeutic alliance is built through a process of rupture and careful repair. Given that we cannot train (ethically or practically) low-intensity therapists in the complexity of human psychodynamics to be utilised in a clinical setting with patients, we can reach a place through understanding ourselves where we can effectively monitor, attempt to change, and choose how we respond to patients, as clinicians.

Becoming a low-intensity supervisor and university marker Clinical supervision is something that I highly value, and have at times idealised my supervisors, admittedly I have also had the odd one that I threw in the rubbish bin before we even got started. I enjoy learning from the knowledge and different ideas and approaches of others, as well as sharing my own experiences and pitfalls within the role. Most of all, I enjoy helping people to learn and develop their skills and confidence, not dissimilar to psychotherapy. Yet, how feedback is given and received, particularly where problems have occurred can be challenging and inevitably involves interpersonal processes, again, similar to psychotherapy. When reviewing or marking trainee practitioners’ clinical recordings of live sessions with their patients, it is much easier to hear and see the interaction between the practitioner and patient than when you are live with a patient in your clinic room or space. When I first trained as a low-intensity supervisor, I would see and hear things during trainee recordings that I could not quite put my finger on about what it was that made me feel uncomfortable, or the opposite, where the hairs on my neck would stand on end, or feel warm inside when seeing or hearing the interpersonal exchange, albeit much of it I recognised from my own clinical practice during training. Becoming a supervisor was where I really began to critically reflect on my own practice and subsequently improved my practice. However, the problems I was hearing in supervisee recordings became more apparent as I began training in relational and psychodynamic approaches, whilst at the same time supervising trainee PWPs and university marking on a part-time basis to support me financially through training. I would also hear from other supervisors and markers I worked alongside, as well as those who I have done supervisor’s supervision with, making comments such as “they were technically okay, but I wouldn’t want them seeing my friends or family.” What was difficult here was that it was easy to feedback an observation of a strong therapeutic alliance to trainees (Box 9.4):

Box 9.4 This session was very collaborative, you demonstrated empathy, compassion, and spent a lot of time clarifying the patient’s understanding. It was clear you are working together on what is meaningful to the patient.

However, defensiveness, or potentially harmful responses on behalf of the practitioner, was far trickier to navigate and articulate in a way that was not overly bruising and could be given room to be thought about within a low-intensity framework.

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Barriers to the interpersonal alliance Many patients will struggle with interpersonal closeness, as can therapists, including low-intensity practitioners. Essentially, if both the patient and practitioner are engaging with problematic interpersonal processes that are outside of the awareness of both the patient and the practitioner, then how can a meaningful relationship be formed? More so, how can therapeutic work then be done? If, as psychological practitioners, we are neither self-aware, unaware, or unwilling to explore our own interpersonal style of relating and reluctance for closeness in relationships, then how can we effectively attend to our engagement competencies? Engagement in a therapeutic relationship effectively requires two people to develop professional intimacy. If both the patient and the practitioner struggle with intimacy, are highly defensive, or are unwilling to monitor and explore their own emotions, responses, and actions, then change is unlikely to take place on either side of the therapy room. However, if we strive to keep ourselves in the healthy middle of the seesaw of valuing through our interpersonal practice, the practitioner can be more securely grounded, and more able to offer a stable position on which the patient can navigate. This is by no means to suggest that simply offering the patient a stable and safe base leads to the patient suddenly increasing the amount of out-of-session work they do, having more motivation for change, or attending more regularly. We obviously cannot and should not control the processes of others. Yet, by holding ourselves in a more realistic and compassionate position, we can be more sure that this is the process of the patient, as opposed to the problematic processes of the practitioner. We can also better manage self-blame and weather the potential devaluing of our contribution to the patient’s experiences when we can reflect more objectively. It is also important that supervisory systems can consider where practitioners may be describing their work through a lens that fits a more rigid worldview, as opposed to an objective and self-reflective process, particularly when working with risk and the potential impact on access and outcomes.

Low therapeutic alliance Low interpersonal alliance can range from the explicitly obvious, for example, a patient and a practitioner entirely out of sync, to the point of arguing and butting heads with each other at an impasse, to the more common, subtle, and covert, such as lack of containment to the session, lack of focus on the patient’s problem, and distractions to the task at hand. There are many ways in which a poor alliance can form, one of the most common I saw when supervising and marking trainee session recordings was either a tendency for practitioners to devalue their own worth in the relationship as an “I am of no use to the patient” practitioner (Fig. 9.2), not feeling able to challenge problems with engagement, patients talking about everything bar the problem they wanted help with, and practitioners giving lots of validating statements but acting as though they had been taken hostage.

FIG. 9.2  ‘Good’ and ‘bad’ patients.

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Another common problem was a lack of personal awareness when working with highly compliant patients, oblivious to the practitioner’s own perfectionistic need to be a brilliant practitioner, engaging with controlling tendencies, dominating the session, dismissing important information, instructing and dictating rather than working alongside their patient. I often described this in my feedback to trainees as being “focused on getting through the session, rather than being with the patient.” Essentially, a less direct version of what I wanted to say, but with hesitation based on the fact that there is no training on the interpersonal relationship in low-intensity training courses. Yet, interpersonal misalliance can be highly problematic but go unnoticed where patients and practitioners have very similar traits. For example, both avoiding conflict and criticism, or the opposite where they both try to take control or dominate the session. Here we might also observe more subtle cues, such as excessive admiration and praise for “the good patient,” or attempting to control “the bad patient” during the session in order to get through their recording. Naturally, a PWP assessment or treatment recording is no easy task, and it can be hard to strike a balance. Yet, it could commonly lead to problems awarding sufficient marks for interpersonal competency, despite the fact that the trainee may have demonstrated a near perfect timing and accurate information giving. It is also common when moderating or calibrating marking for university training courses that different markers will pick up on different aspects of the interaction, and if we are not careful we can end up marking or feeding back to trainees on a “like me” basis. It is important that as supervisors and markers, we are also self-reflective and not simply dismiss or devalue quality work that perhaps meets the competencies more broadly, but is not being delivered in the way we might deliver it, and award lower marks as a result. Whether you are a trainee, qualified, or supervising practitioner, we can all be capable of delivering textbook lowintensity intervention, but if the patient is neither buying into the model, being talked over, instructed, schooled, or the opposite, dominating the session with distraction and intellectual discussion, then regardless of how adherent to the fidelity of the LICBT protocol you stay, the further away from effective interpersonal competency you go. Unless there is a reasonably strong and developed working alliance, a balanced collaborative exchange (which may look different depending on personality and style), you can deliver a technically accurate intervention, badly.

Avoidance and control First, if we consider avoidance at its very basic level as being our ability to consciously distance ourselves from something or actively stop ourselves from doing something. Let’s say for argument’s sake that as an adult I got bitten by my neighbour’s dog. Whilst being a little shaken afterward, I have grown up with dogs my entire life and understood that my neighbour’s dog was a rescue and likely frightened, and I approached it too quickly. I have never avoided dogs since being bitten. Yet, had I been bitten by the neighbour’s dog as a child, and had never grown up with dogs, I might have developed a fear of dogs into adulthood. I might avoid them altogether, petrified to be anywhere near them, in complete avoidance. Alternatively, I might be able to walk through a park where there are lots of dogs on leads, but if I was unable to avoid a dog running around off their lead, I might opt to curse at the owner, shoo away the dog, or call the dog warden in an attempt to control the situation that is generating anxiety. My ability to tolerate closeness to dogs may also differ based on the size, body language of the dog and whether or not it is growling at me. Here, my past experience combined with my perceptions in the here and now can shape what and when I might avoid, approach, or attempt to control in response to a similar stimulus (a dog). The more implicit processes of avoidance and control related to interpersonal stimuli (people in individual or group situations) can create complex and strong emotions related to our early experiences in relationships and our internal sense of self-image, e.g., wishing to avoid criticism, interpersonal conflict, or shame. Whilst this can often be common and normal, it can also be problematic where this is a more marked pattern, particularly as a therapist working clinically with patients who also experience strong and complex emotions when faced with interpersonal stimuli. The more problematic processes of emotional avoidance and interpersonal conflict that are formed in earlier life are often unconscious and automatic and stem from our earlier experiences in relationships, including family and school. At the risk of making very sweeping generalisations here (which is not the intention), I am referring to processes that can be common in people more generally, in that we can all have a tendency to want to avoid or control a situation at times in our day to day lives, given different circumstances. However, to attempt to highlight how these processes can be problematic in relation to clinical interactions, and trying to keep this simple, I will refer to two of the more commonly witnessed problems with interpersonal processes in low intensity practice as ‘cheerleaders’ and ‘quarterbacks’. It is important to reiterate that anyone can have a tendency to be a bit of both at times, the key thing is our capacity and ability to reflect on it.

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Cheerleaders The concept of a cheerleader is likely to bring to mind an image of someone wearing a spandex outfit with glitzy pompoms being energetic and loud. This is not the context I am referring to. Essentially, cheerleaders in low-intensity practice can come in all shapes, sizes, genders, and on a spectrum from introvert to extravert. What I mean by cheerleading is more the way in which someone approaches their clinical interaction in terms of the distance within the therapeutic relationship and the sense of their role with the patient. For example, in American football, cheerleaders serve a function of morale and encouragement but technically to the point of idealising. Regardless of whether the team they are cheerleading are at the bottom of the league or the top, play brilliantly or badly, win or lose a game, they continue to chant “our team is great.” It would appear quite odd (and unlikely they would be asked to cheerlead again) if they were more realistic, “our team generally plays well but last time they got hammered on points by the Eagles.” The role of the cheerleader is to be positive and rally the team regardless of the reality of the situation, and no doubt likely of some benefit to the team in terms of maintaining morale in the face of defeat. Yet, their position in terms of distance to the team is on the side-line, they do not get involved in challenges, and never touch the ball. If we consider this in the context of avoidance and the interpersonal alliance in therapy, the patient is left unchallenged, navigating the ball and the goal alone, albeit with a high level of cheering from the sideline whilst they are doing it, regardless of their ability or understanding of the intervention (Box 9.5).

Box 9.5 Marie has been undertaking LICBT using graded exposure to help with panic attacks. She had previously seen a PWP the year prior and recovered. She re-accesses her local IAPT service again for support following a conflict with her second ex-husband over unpaid car payments after their recent divorce. Her ex-husband had agreed to keep his name on the finance as Marie could not get finance in her own name due to unpaid credit card debt from her first marriage. Marie stated that she would rather catch the bus and give up the car than deal with her ex-husband and intends to sell the car once she overcomes her panic attacks. She did not want to access high-intensity therapy, despite longer-term problems with anxiety and low mood, and had requested LICBT again. Her scores at assessment were in the severe range for depression (PHQ-9: 23), and anxiety (GAD-7: 21), and also scored high on avoidance for phobia (7 out of 8). Marie’s goal was to reduce her anxiety about catching buses which lead to panic attacks. This is her third session, including the initial assessment with the service. The low-intensity practitioner has just done a review of Marie’s problem statement, goals for treatment, and current thoughts of suicide or self-harm. PWP: So, Marie, how did you get on with your out-of-session task? I think you were moving up the hierarchy to the more difficult situations this week, catching a bus if I remember correctly? Marie: Yes, that’s right [sounding very pleased], well, thanks to you and all of your hard work. I can’t believe I’m even saying this…I DID IT!! I CAUGHT THE BUS!! PWP: WOW!! Oh, I’m so proud of you Marie, you are amazing! How does it feel? Marie: Honestly, I feel so great. I would never have believed that I could have achieved this in such a short time. It’s all thanks to you! [idealising—other]. PWP: Honestly, Marie, I haven’t done anything at all [devaluing—self] it’s all your hard work. Marie: Honestly, I can hardly believe it, I feel so much better. PWP: I’m so excited to hear about what happened on the bus. Marie: Well, I’ll admit I still have a few ‘bad days’, I struggle to fill out those measures and scores, you know I do, I’ve told you before. PWP: Yes, yes, Marie, you have told me that you close your eyes when you fill the scores in, but you do really well with them. Marie: Thank you, and you know that I still get panicked and my mood still gets bad during the evening. PWP: Every evening, or just a few evenings? Marie: Every evening. PWP: You’re doing brilliantly and I can tell by the sound of your voice that you are better. How would you describe your mood over the week? Marie: Better. PWP: Yes, that’s right. And you’ve also got evidence to prove it haven’t you? You achieved your goal of getting on the bus! Marie: Well, the bus, that was an experience, but I got through it. I’ll admit, I was all over the place in the morning, but I kept saying that mantra that you told me about “that flutter in my stomach is a sign of the belief in myself,” in fact it was like I had your voice on my shoulder saying it to me! PWP: That gave me goosebumps, Marie.

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Box 9.5—cont’d Marie: Well, I couldn’t have done this without you, you’ve been my rock through all of this. PWP: That’s so lovely to hear, but you have done the hard work Marie, remember that. Marie: I try; I try to remind myself of that. But you have been so good to me. You know how badly I was treated by that terrible therapist who used to criticise me last time [devaluing prior therapist], they just didn’t get me, telling me I wasn’t doing things properly. I tried, you know! I did try! But you don’t do that to me. I’m so grateful to have found you. PWP: You are so kind Marie, really so kind. So, the bus, what happened when you got on? I’m excited to hear about it. Marie: Well, as I said, I was in a total state that morning and, well, I know they are technically ‘a safety behaviour’ but I had a phone call later that day with my ex-husband. And, well, you know how I get so drained with that. PWP: Yes, you do get drained with the calls to your ex-husband, I remember you saying that. When you were married you tolerated a lot of criticism from him, didn’t you? Marie: Yes, I did, and I just couldn’t deal with that on top of my therapy, so I did what I had to do to get through the graded exposure. Like you said the last session, it’s important for me to do self-care. PWP: Yes, self-care is crucial to you right now Marie, with everything you are going through with your ex. What did you do for self-care? Marie: I took 4 mg diazepam. PWP: 4 mg diazepam? Marie: Yes, no way I could have got on the bus otherwise, not with everything else going on. PWP: Well, you must have needed it. As you say, you had the phone call with your ex on top? Marie: That’s right. I did! PWP: Sure, and how far did you go on the bus though? Did you make it to town? Marie: Well, I also have to confess that the diazepam wasn’t technically mine. PWP: It wasn’t yours? Marie: No, a friend gave me it, just one strip, I’ve lent her mine in the past, so I called in a favour. PWP: So you borrowed it? Marie: Yes, just the one strip. PWP: From what you are saying, it helped you to ride on the bus. How did that go? Marie: Three stops. PWP: Three stops. Marie: Yes, there was no way I could manage any further. I just kept thinking about the phone call and I was feeling really dazed from the diazepam, turns out my friend takes a high strength, I was worried that I would pass out and there were some very unpleasant looking people on the bus, I was sure they would steal my purse. I thought ‘what would my therapist say?’ I thought ‘I need self-care’ so I got off and walked home. PWP: But you got on the bus! And remember, self-care is so important right now! Marie: It is, and I’m so glad you keep reminding me of that. Don’t know what I will do when our sessions finish. How many do we have left? PWP: Bless you. It’s so great to work with you and we have three sessions left. Marie: [tearful] oh goodness. PWP: You are in recovery Marie, don’t underestimate how well you are doing, we can always think about extending if we need to, don’t worry about the sessions. Marie: That’s great, you are so kind. PWP: You’re the one doing the work here, Marie! Marie: That’s right, I’m doing well, that fluttering in my tummy is the belief in myself. LIT: Oh, goosebumps, again. [sessions ends at 48 min]. The session notes completed after the session by the practitioner were as follows. PHQ-9: 6 GAD-7: 4. Risk: No concerns. Problem statement review: Patient still feels the problem statement is reflective of her difficulties but is now “feeling great.” Goal review: Achieved therapy goal of catching the bus. Review of out of session task: The patient is demonstrating a very good awareness of safety behaviours and has managed to successfully move up the hierarchy. She experienced many challenges in the run-up to her exposure task and although she did take medication to help her with the bus, she is aware this is a safety behaviour. We reflected on how she is clearly demonstrating progress, objectively evidenced in her MDS scores that are now under caseness. Normalised the current situation with her ex-partner. Has found the intervention helpful and offered very positive feedback as to our therapeutic alliance. Out-of-session work: Self-care and working up the exposure hierarchy, planning to take another bus ride for longer this time. Plan: Currently in recovery, review at session five for discharge but may need an extension for relapse planning due to prior problems with sustaining gains last time.

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As a supervisor reading the clinical notes, at first glance, it would indicate that the patient is doing well and would be ready for discharge. However, when looking at the large reduction in scores over a very short period of time, I would be curious as to what that was about. Potentially here I might be wanting to ask the PWP what their thoughts were in terms of the significant shift in reporting. Whether or not there was a possibility the patient might be purposefully underscoring, given the note from the PWP stating that the patient might require additional sessions and the patient previously relapsed after discharge during the last episode. Yet, the PWP is also noting that the patient is running at full speed with the intervention and has a good grasp of safety behaviours and this links to the problem statement and goal, meaning that it would be important to discuss this in more detail. However, on listening to the recording of the session, it is apparent that the patient presents with a risk that has not been addressed and is taking controlled medication without a prescription that requires their GP to be updated. In addition, it is clear the patient is neither applying the principles of graded exposure, nor benefiting from an evidenced-based lowintensity intervention, given that the PWP is also going off the grid talking about self-care, without actually discussing with the patient what this means at a practical level, e.g., how does self-care form part of the intervention (whether relaxing and pausing in the day, or physical self-care such as bathing and eating)? The primary reason the intervention is problematic and reduces the patient’s opportunity for progress is that both the patient and practitioner have formed a misalliance. They both have similar interpersonal processes (avoidance of criticism and conflict). The patient is effectively telling the PWP that she does not want to be criticised for getting things wrong, and the PWP, fears upsetting the patient and does not help the patient to see or challenge their problems with engagement around the change method.

The quarterback It is important that I point out at this point that I am not a huge fan of sport and know absolutely nothing about American football, despite making reference to it on more than one occasion. But, I have it on good authority that the quarterback is a key player in a football team, typically drives the game from a position behind a front line defence, nearly always has hold of the ball and is typically the player most often to throw the ball in offensive play (apologies in advance to sports fans everywhere). Needless to say, the quarterback likely holds an important role if you are playing American football, but in terms of low intensity therapy, being defended, with the primary focus of the session being forcibly driven towards the goal, whilst being the one mostly controlling the ball, is not conducive to an effective learning environment or therapeutic alliance (Box 9.6).

Box 9.6 PWP: So, Marie, we have 30 min for the session today, and we will be going through the usual things, review of risk, measures and homework. Anything you want to add or is that okay for now? (devaluing—other). Marie: Well, I DID IT!! I CAUGHT THE BUS!! PWP: I’m sorry, what do you mean you caught the bus? Marie: I caught the bus, I literally can hardly believe it, I just thought to myself… PWP: [talking over the patient] Before we go into that I need to cover risk as we would normally. Is that okay? Marie: Okay, well, yes, sure. I’ve been fine though, no thoughts, I put that on the PHQ-9. PWP: Have you had any thoughts of suicide in the past week? Marie: No. PWP: Have you had any thoughts of self-harm in the past week? Marie: No. PWP: Are you neglecting yourself in any way? Marie: No. PWP: Are you at risk of neglecting anyone else in your care in any way. Marie: I don’t have anyone else living at the house. PWP: Is that no? Marie: Yes, I mean, no. Oh dear, sorry! PWP: That’s great, Marie. So, we will now go through your measures as we normally do, you scored six on the PHQ-9 this week and that has come down from 15 last week. Marie: Honestly, I can hardly believe it, I feel so much better. PWP: So you would say that your scores match how you are feeling, have I got that right? Marie: Yes, and I dealt with a really difficult call with my ex-husband this week as well, you know how I told you that I had ­problems with him…. Continued

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Box 9.6—cont’d PWP: [talking over the patient] Yes, Marie, you have told me about your ex-husband, but if we could just focus on this section of the session before we get to that. You scored four on the GAD-7 and that was down from sixteen last week, which means you are now in the clinically healthy range for worry and anxiety, would you say that matches how you have been feeling? Marie: Yes. PWP: And your goal is still to get on the bus? How would you rate your motivation towards your goal? Marie: Oh, I feel very motivated. PWP: Can you rate that zero to ten? Marie: Oh, eleven! PWP: Eleven! That is great! You sound really motivated! Marie: Oh, yes, I am! PWP: Great stuff. Okay, Marie, so we will now move on to the homework review. You mentioned that you managed to get on the bus? Marie: Well, the bus, that was an experience, but I got through it. I’ll admit, I was all over the place in the morning, but I kept saying that mantra that you told me about ‘don’t think, just act’, in fact it was like I had your voice on my shoulder say… PWP: [interrupts] Do you mean ‘your thoughts are not facts?’ Marie: I beg your pardon? PWP: The phrase I told you was ‘your thoughts are not facts’. Marie: [laughing] ah! Okay, sorry about that, my fault! PWP: That’s okay, but it is important that we clarify your understanding of the intervention. Marie: Well, I couldn’t have done this without you; you’ve been my rock through all of this. PWP: That’s great to hear, Marie [idealising—self]. So can you tell me how your homework task fits with your goals in terms of the five areas model? Marie: Well, as I said, I was in a total state that morning and, well, I know they are technically “a safety behaviour” but I had a phone call later that day with my ex-husband. And, well, you know how I get so drained with that… PWP: [talking over the patient] Can you tell me what the safety behaviour was? Marie: Oh! …erm…I’m not sure what you mean. So sorry, I… I’m in a fluster. I’m so stupid! [devaluing—self]. PWP: Can you tell me where the safety behaviour would sit in your vicious cycle, Marie? Marie: Well, erm, [long pause], I, well I was thinking…erm…[pause]…yes, that’s it, I got off the bus! PWP: So, if you remember, we talked about the vicious cycle, your thoughts link to your feelings and behaviours, but some behaviours we engage with under the false belief that it stops us feeling anxious or being at a greater risk of having a panic attack. Do you see how that fits with your vicious cycle? Marie: Oh, yes. I see that now. PWP: And how do you think getting off the bus would link to your problem statement and goals, Marie? Marie: Well…I’m…oh…erm… I guess it would stop me from getting on another bus? Yes, stops me from getting on another bus. PWP: Well no, it would potentially give you the false sense that getting off the bus was necessary to stop the panic. A safety behaviour. We talked about this in terms of the fight and flight last session, Marie. What do you remember about the fight and flight? Marie: Ah, I see. I’m so sorry I’m trying very hard at this, I just don’t seem to be able to get it right, I’m so stupid. [devaluing—self]. PWP: That’s okay, Marie. But if we are to sustain your progress it is important that you are properly applying the technique, certainly if we are to keep your scores under the clinical threshold for recovery. Marie: Yes, that is important. I’m so glad you keep reminding me of that. Don’t know what I will do when our sessions finish. How many do we have left? PWP: Well, technically you are now in recovery and we have six sessions in total including your assessment, so it is important that you apply the technique next week before we do relapse planning. Marie: Oh dear! Really? PWP: If you remember, we talked about this at the assessment session, my job is to help you to understand the tools, the tools are then yours for life. Marie: Oh, yes. I remember now. PWP: So, it is 24 min into the session now, Marie. What I would like you to do for me for next week, is to read back through the workbook from pages 7–9, about the fight and flight, as well as safety behaviours, and then reattempt the homework task of getting on the bus, also go through and list the safety behaviours that you use and try to eliminate them. Marie: Oh goodness, really? PWP: Do you foresee any barriers to undertaking your homework task, Marie? Marie: No, I will definitely try to apply what you have said and I will give it a good go. PWP: What day and time will you do it?

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Box 9.6—cont’d Marie: Oh! erm…well, I’m not so sure…I have…erm…hang on, let me get my diary…it is in my bag somewhere [rustling sound] …damn! Where the hell… is…I’m so sorry about this… PWP: [interrupts] Don’t worry about that for now, Marie. So we have covered your risk, your measures, your homework, and identified how your recent problem with the homework task fits with the five areas model. You have linked this to your goal, and will reread pages 7–9 of the workbook, listing safety behaviours and trying to eliminate them from your next graded exposure task. Maybe put a time and day in your diary when you find it after the session. Does that sound like an accurate summary of what we have discussed? Marie: Yes, it does. Perfectly! PWP: How have you found the session today? Marie: Oh, fantastic as always. PWP: Great to hear. See you next week. Marie: See you next week. [session ends at 28 min]. The session notes completed after the session by the practitioner were as follows. PHQ-9: 6 GAD-7: 4 Risk: Denies thoughts of suicide or self-harm. Denies self-neglect or neglect of others. Goal review: Is nearing her goal of catching the bus but using safety behaviours. Review of out of session task: The patient attempted the homework task from last week of catching the bus. Able to relate this to the vicious cycle. Out-of-session work: Reset the homework from last week and asked to reread pp. 7–9 of the workbook on fight and flight and identify own safety behaviours and then reattempt the task whilst eliminating safety behaviour. Plan: currently in recovery, review at next session. Will discharge if scoring under caseness after two consecutive sessions with a robust relapse prevention plan.

As a supervisor reading the notes in this instance, with the same patient, again, it would appear that the patient is doing well and is ready for discharge, albeit with some additional support required around eliminating safety behaviours. I might be inclined to discuss with the PWP in a little more depth about the patient’s understanding of the LICBT material given the repeating of the homework, I might also ask whether discharging the patient in the next two sessions might potentially require some extension, despite the scores. Again I would like to discuss the swift reduction in PHQ-9 and GAD-7. Yet, reading the clinical notes it looks as though the PWP has covered things quite thoroughly in terms of adherence to LICBT. However, listening to this recording, the PWP devalues the patient’s input from the offset during the initial sequence of the session “would you like to add to the agenda, or is that okay for now?” As a supervisor and university marker, the opening sequence of a recording gave me a lot of information about how the PWP and patient operate, the general sense of their alliance if this is a few sessions in, and I would listen attentively to what is happening, not simply whether the PWP is adhering to agenda items for examination purposes. The PWP then goes through a risk assessment like a military drill and it is far too premature within the session. This effectively shuts the patient down early on and they are then heavily controlled for the remainder of the session. The patient then becomes flustered, loses her thoughts, and is not given time to think when she is pressured for a response and instead defends herself through compliance and self-devaluing. As a consequence, the patient does not disclose taking the diazepam given to her by her friend. Mostly because she does not have time to speak or gather her thoughts, but it is also likely that she might withhold this information if she is perceiving the potential for criticism from the PWP (her mode of operating in the face of pressured interpersonal stimuli). Again, the patient and PWP are operating on patterns outside of conscious awareness and the patient is not given an opportunity to learn and understand the intervention, in favour of the PWP getting through each of the components within their session time.

The reflective practitioner: Compassionate challenge The following example is a potential dialogue between the same patient and a low intensity practitioner who sits more comfortably in the middle of the seesaw of valuing. They use core low-intensity practitioner skills whilst also adhering to the principles of the LICBT method. The main difference here is that they offer a more pragmatic, and realistic approach to the patient and their work, they are more self-aware, reflective, and demonstrate learning through critical practice and utilising supervision effectively and nondefensively (Box 9.7).

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Box 9.7 PWP: So, Marie, how did you get on with your out of session task? I think you were moving up the hierarchy to the more difficult situations this week, catching a bus if I remember correctly? Marie: Yes, that’s right, well, thanks to you and all your hard work, I can’t believe I’m even saying this, I DID IT!! I CAUGHT THE BUS!! PWP: You sound really pleased Marie; I’m really interested to hear about how you got on. Marie: [tearful] Honestly, I feel so great. I would never have believed that I could have achieved this in such a short time. It’s all thanks to you! PWP: That’s kind of you to say, Marie, I wonder what else might have made a difference? Marie: I’m not sure what you mean. PWP: In terms of the skills that you have been building outside of the sessions. Marie: Well, I was in a total state that morning and, well, I know they are technically ‘a safety behaviour’ but I had a phone call later that day with my ex-husband. And, well, you know how I get so drained with that. PWP: You felt anxious about the phone call with your ex-husband and that increased the pressure that you felt doing the exposure task, have I got that right? Marie: Yes, it did, and I just couldn’t deal with that on top of my therapy, so I did what I had to do to get through the graded exposure. It’s important to me that I can still do my therapy, I don’t want to let you down. So, I took 4 mg of diazepam, which my friend gave me. PWP: 4 mg of diazepam? Is that what you were referring to as the safety behaviour? Marie: That’s right. And I know it’s a safety behaviour, but it was the only way I could get on the bus. PWP: I think it’s great that you have a good understanding of safety behaviours, Marie. I’m a little bit concerned when you say that your friend gave you diazepam though. Marie: We share medications, and help each other out. Did I get something wrong? Please don’t tell my GP! PWP: I think it is great that you have a friend that cares about how you are feeling, but we also need to care about your safety, Marie. Diazepam is a controlled drug and I have a duty of care to record what you have told me and to inform your GP. How do you feel about me doing that? Marie: [weeping] I’m so sorry, I’m so stupid, I just get into these things, I don’t manage. PWP: There is no need to apologise, and I do not think that you are stupid, we can all make mistakes when we are stressed, but your safety is really important. Are we in agreement that I will update your GP, Marie? Marie: I guess so. I just struggled with the thought of the bus. PWP: I’m hearing that was challenging for you. What happened there? Marie: I got on the bus and then got off after three stops. PWP: Three stops, what happened when you got to the third stop? Marie: There was no way I could manage any further. I just kept thinking about the phone call and I was feeling really dazed from the diazepam and worried that I would fall asleep and there were some very unpleasant looking people on the bus, I was sure they would steal my purse. I thought “I don’t feel well” so I got off and walked home. PWP: I wonder if it would be good to capture this in a five-areas cycle as we speak, Marie? How would you feel about that? Marie: Erm. Is there a reason you want to do that? I much prefer to speak with you; you know how much I value our discussions. PWP: I value speaking with you also, Marie, but I think this would be a good way for us to clarify what happened for you when you approached the exposure task. Perhaps we might deepen our understanding of this, together? Marie: Okay, if that is what you would prefer to do. PWP: This isn’t about what I would want, Marie, it’s important that this is something that you would like to work on. Marie: Yes, it’s okay, I am happy to give it a try. PWP: You were anxious in the morning about the exposure task, then feeling more stressed about the phone call with your exhusband, have I got that right? Marie: Yes, that’s right. PWP: Then you approached getting on the bus using 4 mg of diazepam, but that made you feel dazed and unwell so you got off the bus. Is that correct? Marie: Yes, that is right. PWP: How would you work that into the five areas from what we have been discussing over the past few sessions? Marie: Well I used a safety behaviour didn’t I. But I couldn’t have gone through with that and the phone call. I just couldn’t have coped. PWP: Do you see anything else that might be a barrier to doing the task in that five-area cycle, Marie, when you think that you will not cope? Marie: [long pause] I’m not really sure what you mean. PWP: If we think of how the fight-flight operates? Marie: [long pause] Ah! I got off the bus! PWP: Yes, I’m also wondering what else might have been happening when you decided to approach the task. What might have got in the way? Marie: The phone call with my ex-husband? PWP: You did mention that it had increased your anxiety and left you predicting that you would not be able to cope.

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Box 9.7—cont’d Marie: That’s right, it did! PWP: I’m wondering what might be useful to consider when approaching that task again this week? Marie: You want me to do it again? PWP: This isn’t my therapy Marie, you don’t have to do anything you do not wish to do, but I’m curious as to whether you might want to try again whilst trying to remain on the bus without the diazepam until your anxiety reduces? Marie: Well, I would rather not do it, to be honest. PWP: That’s useful information. I wonder what is in the way of that, for you? Marie: I just don’t think I would be able to do it. PWP: To get on the bus? Marie: I need to be able to get on the bus, but I just can’t see it happening. PWP: If this is still a goal that you would like to achieve, maybe we could take a step back and think together about interim steps. Marie: Actually, I just don’t want to use the bus, I really hate buses. I really want to keep my car, maybe I should keep speaking to my ex-husband? I feel so lonely after the divorce and it upsets me each time I think about it. PWP: I think that is a very important reflection, Marie. I imagine that must feel like a really tough situation to be in. I wonder how you feel that LICBT might help with that? Marie: I’m not really sure. PWP: Again, that’s really useful information for us to think about in terms of next steps. Perhaps we could put this on the agenda for next week to discuss a little further? How does that sound? Marie: I think that sounds like a good plan. It will give me a bit of time to think as well. Thank you for taking the time to speak to me today, it’s been helpful. PWP: It’s my pleasure Marie, and thank you for your contribution to the session too, it’s been very valuable. Take care. Marie: Take care. (session ends at 32 min). The session notes completed after the session by the practitioner were as follows. PHQ-9: 6 GAD-7: 4: Whilst the patient is scoring underneath the clinical range on both measures, objectively the patient has articulated these may not be reflective of her current experience. To discuss further in supervision. Risk: Patient denies any current thoughts of suicide or intentional self-harm, but disclosed during the session that she has been taking 4 mg nonprescribed diazepam and stated that she borrowed these from a friend and regularly shares prescribed medication with them. I have spoken with the GP at the surgery who has agreed to call the patient to discuss this. I have made the patient aware that there are safety risks when taking nonprescribed medication and have informed her that I will be updating her GP. The patient appeared worried about this but accepted that I have a duty of care. I have also updated my supervisor. Goal review: Her initial goal for treatment was to be able to catch a bus without having a panic attack. However, she has admitted today that she is ambivalent about wanting to achieve her goal. Problem statement review: The patient indicated during the session today that she feels lonely and some of the problems may stem from the relationship with her ex-husband. Review of out of session task: The patient attempted the homework task from last week but using nonprescribed diazepam and did not manage to remain in the situation, getting off the bus after three stops in response to the effects of diazepam. We talked through the five areas and the patient was able to identify a safety behaviour but struggled to notice cognitive barriers to implementing graded exposure. Out-of-session work: No specific LICBT homework was set for the patient this week. We have agreed to discuss what she may need going forward, and have put this on the agenda to discuss next session due to limited time to explore this today. Plan: To discuss the case in supervision as to whether I should consider modelling cognitive restructure around her thoughts of not coping during the exposure task. A possible case for stepping up, but I need to assess motivation for change at the next session before considering this.

The clinical notes and the clinical recording objectively match what happened in the session. The practitioner is thinking about the wider context involved with the patient including their suitability to LICBT, reporting of outcome measures, and risk. As a supervisor, I am clear from the notes as to what is needing to be discussed, and I am likely (given the notes and the recording) to trust the clinical judgement of the supervisee in terms of what they would like to do next. My role here would be to support and think with the supervisee, and of course, give some encouraging and positive feedback on their clinical work with the patient.

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Addressing problems with interpersonal skills The primary challenge here in supervision is how to help practitioners to identify problems with their interpersonal skills and create sufficient space for the feedback to be thought about without eliciting major defensiveness or trying to do personal therapy. The way in which we approach this will often vary depending on the individual. As a supervisor, I am typically quite direct, as opposed to dancing around the edges, and this is my preferred way of being supervised myself. Yet, on occasion, despite good intentions, my feedback has landed like a house brick through glass. My personal view here is that if we are blind to our blind spots, gentle tip-toeing around the five areas cycle is unlikely to do much to bring the problem to awareness, but feedback (regardless of how necessary) has to be done with care and will often depend on the strength of the supervisory relationship. Hence, it is important to establish a healthy working alliance from the outset. The other side of this is that we need to offer a compassionate and safe space to support learning from practice. It is common for practitioners, particularly trainees, to only record their work with “good” patients who offer more textbook dialogue during the session, sufficient that the practitioner can demonstrate “brilliant” competency. Given the reality of clinical work is rarely textbook, practitioners who do not bring recordings where they are seeking development and wishing to better understand where problems and ruptures have occurred are typically red flags for me as a supervisor, and I will normally address this early on and encourage supervisees to bring recordings where they are stuck or feel unhappy with aspects of the session. Essentially, consistently brilliant work in any psychotherapeutic modality is both unrealistic and unlikely. Personally, my way here is to break the cardinal rule of low intensity practice and ask the supervisee how they feel with their patients, literally, “what do you notice about your feelings when you are talking about the session?” If I have a supervisee who honestly states something along the lines of “they frustrate the hell out of me!”; in most cases, this leads to something more productive, opening discussion and awareness of what might be getting in the way of the relationship, as opposed to, “I reflected on it and think perhaps that I am stressed and need more self-care myself.” Which might be true, but it is vague and tells us absolutely nothing about the problem or how to tackle it. Through honest, safe, and protected spaces in supervision, and to reiterate this is key, you are far more likely to gain ground. You risk offering a potentially damaging relationship with your supervisee (and subsequently with their patients) if you are constantly nipping off to discuss the supervision session with your line manager or own supervisor every time the trainee or supervisee discloses tricky material, leading to anxiety from the supervisee to disclose. Of course, there will be times when we need to do this, but in my experience, this is not so often. We are also more likely to get a better sense of how the patient is being experienced by other people in their life outside of sessions if the PWP feels safe to discuss the reality of what happened in the session. For example, if the patient is having problems making and sustaining relationships but is experienced as irritating the hell out of the practitioner, it is quite possible that the patient may be having the same effect on others. This can also work in reverse, and upon listening to the recording, it may become apparent that the problem lies more in the similarity of processes between the patient and practitioner, or something more about the process of the practitioner, which, if left unaddressed, is potentially a pattern with other patients during their clinical work. Some approaches may opt for going with the proverbial negative sandwich, “you did this well, perhaps there is some consideration here, but you also did well here, and here.” My personal approach is typically a little more direct and to the point of the problem, “I noticed this happening, what do you make of that?” Although less common, we can also encounter extreme and marked problematic interpersonal patterns from clinicians, particularly when they are undertaking a very pressured training course (typically in the minority of trainees, but one or two do appear in each cohort) which can result in equally extreme responses to clinical feedback. On the odd occasion, I have received very concerning responses from trainees, unpicking the learning points that have been offered when marking a clinical recording for examination purposes, where there were very significant interpersonal problems being highlighted, and had also been highlighted by other supervisors and markers. Yet, it appeared to be entirely unacceptable to the trainee who demonstrated heavy resistance against any inward reflection. In one particular case, the trainee went as far as denying what was said during their interaction with the patient, despite the audio recording. Which, those who are seasoned lowintensity supervisors, would likely agree this leans towards potential fitness to practice issues. Whilst much of my own supervision post IAPT has been process-based, one of the more helpful models I have come across is the Seven Eyed model of supervision (Hawkins and Shohet, 2006), which is described in more detail in Chapter 10, Supervision. Whilst this is likely to be costlier in terms of both time and labour, the potential benefits and cost savings for improved clinical decision-making and delivery of useful clinical work, are likely to have a beneficial impact on both outcomes and stepping decisions, as well as an opportunity for practitioners to engage more safely and deeply with the interpersonal alliance and therefore better able to apply the technical model and approach.



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Often, a more difficult consideration for people who work in very pressurised systems to think about is the impact of their own processes within systems. This is not in any way to suggest that there are not significant problems with the current system; I would hope by this point of your reading through our book that both Liz and I have explicitly highlighted the significance of the challenges that low-intensity practitioners face in their role, and the common pressures that are created by problematic systems. However, we need to be equally careful (as in the balance required in the seesaw of valuing) that we also have room to be able to consider what part we might personally play as part of those systems.

Reflections from beyond the Emerald city Writing this book whilst also training as a psychologist, I have been reflecting a lot on the challenges during my time across the different tiers of the health service. Whilst I very much enjoy my job and have no regrets about my career choice, and I am also mindful of the privileges that I hold as a result, the ideal that I initially had in my mind at the start of my journey is different to the reality in practice. Part of that reality being that some of the challenges that are common in low-intensity therapy do not suddenly disappear once you train in another role. Essentially, the NHS is an imperfect system steeped with funding and staffing issues and regardless of the step of care that you work at, most people are simply trying to do the best that they can for patients with what they have available to them. I can recall the shift from being angry at the problematic processes in the IAPT system as a PWP, to starting to better understand those processes, noticing similarities present within secondary care services, including waiting lists and funding pressures, using assistant psychologists or support workers to undertake group or individual-based “stabilisation work” (low intensity intervention) to manage the throughput, albeit without the relentless focus on statistical recovery, and integrating concepts rather than using manuals and protocols. I am also more aware now that when I worked as a low-intensity practitioner in IAPT services, I consistently complained about the average of four to six sessions not being enough for my patients, this has also surfaced in my secondary care placement, where twenty to forty sessions were not quite enough for my patients, and in my first year in private practice where patients have few limitations on sessions, I would worry that therapy might be taking too long due to the mounting costs for the patient. This was, of course, all part of my own personal process given the consistent pattern within different contexts, albeit now in my awareness and with plenty of room to reflect on the sense of personal value and responsibility (both internalised and displaced), particularly during times of high pressure. But this was not the case whilst I was working as a low-intensity practitioner as I simply did not have the tools, framework, or language to understand or describe what was happening. Instead, I continued to complain about the processes of systems without being able to balance my own personal contribution against what was happening within that system. I am also mindful of the integrative nature of applied psychology training in terms of the varied therapy models, and the theory underpinning those models. At the start of my training as a psychologist, I idealised psychodynamic approaches, and wished to relegate anything related to CBT to the rubbish bin, followed swiftly by doing the same with person-centred theory. A few years on (and still in my early career stage as a psychologist), I still heavily lean towards dynamic psychotherapy as a therapist, but this is mainly because I believe in and value the concepts and it is my preferred way of understanding and working with distress. Yet, I also value and draw on CBT and Humanistic concepts depending on the needs of the patient, CBT more explicitly when working with NHS patients, as this is more commonly dictated by service commissioning. Essentially, the primary aim of any psychotherapeutic approach, including low-intensity practice, is to offer the person a framework and concepts for which they can best understand their problem in a digestible way, based on the best available evidence, time, and resources. To work collaboratively in supporting changes that are important for the patient, and most importantly, to help the person try to apply those changes to their life outside of the therapy room. The rest, at a very basic level, is how the therapist best understands and believes in their approach, and ultimately how they communicate this to the patient through the interpersonal alliance. So, what is the Emerald city actually like? Well, as is the case in the story of the Wizard of Oz, this is a place that only exists in the minds of those in pursuit of it and, for the most part, is eventually revealed to be a place of mixed experiences, joy, excitement, as well as disappointments and complex interpersonal processes but always learning from the people you meet along the way. It is an endless yellow brick road with no definitive endpoint that you suddenly arrive at, and sadly, there is no magic or wizardry. You still have to navigate high caseloads, high waiting lists, and manage challenging interpersonal dynamics, including professional relationships. You still have to make decisions whether to accept or decline referrals, often those from IAPT services, and there are less onward available services, often you ARE the onward service. Depending on funding, particularly in pressured secondary care teams, your sessions may in some cases also be capped at four to six sessions. You still have to continue to monitor and manage your own wellbeing whilst supporting the wellbeing of others, including risk

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assessment for suicide, self-harm, risk towards and from others, and child and adult safeguarding, write clinical notes and reports, attend clinical supervision, and supervise others. Sounding familiar? The main differences are that typically you have a greater depth and breadth of training in assessment and psychotherapeutic approaches across the lifespan, formulation, leadership, psychometric testing and diagnostics, often holding greater responsibility and accountability for serious risk, whilst also trying to support the relational processes across and within teams. Sadly, the processes of devaluing do not suddenly cease, even between the different divisions of applied psychology. Yet, if we park our brand identities, we are left with humans who sit on a wide spectrum as therapists all trying to do similar things for patients. The range in terms of how we all do this is vast, from brand purists to eclectic integrationists. Here, we might perhaps do better to be a little more open to valuing and learning from each other, rather than devaluing and berating each other. Of course, this all requires a capacity and ability to have sufficient room to reflect on our personal process. As I come to close the chapter on my work with low-intensity therapy, and low-intensity practitioners in IAPT services (physically and metaphorically), the take away from my experience is that no matter how much the system demands standardisation, ‘gold standard’ assessment tools, scrutinised data output, or categorises our different professional titles and approaches, fundamentally, relationships are, and must always be, at the heart of everything that we do. With ourselves, our therapeutic work with patients, our professional interactions, and into our lives beyond the clinic room.

References Festinger, L., 1954. A theory of social comparison processes. Hum. Relat. 7 (2), 117–140. Hawkins, P., Shohet, R., 2006. Supervision in the Helping Profession, third ed. McGraw-Hill Open University Press, Maidenhead. Klein, M., 1932. The Psychoanalysis of Children. The International Psycho-Analytical Library. Klein, M., 1935. A contribution to the psychogenesis of manic depressive states. Int. J. Psychoanal. 16, 145–174. Rogers, C.R., 1961/2012. On Becoming a Person: A Therapist's View of Psychotherapy. Houghton Mifflin, Boston. Roth, A.D., Pilling, S., 2008. Using an evidence-based methodology to identify the competencies required to deliver effective cognitive and behavioural therapy for depression and anxiety disorders. Behav. Cogn. Psychother. 36, 129–147. Tajfel, H., Turner, J.C., 1979. An integrative theory of intergroup conflict. In: Austin, W.G., Worchel, S. (Eds.), The Social Psychology of Inter-group Relations. Brooks/Cole, Monterey, CA, pp. 33–47.

Chapter 10

Supervision James Spiers and Elizabeth Ruth University of Bradford, Bradford, United Kingdom

Key aims of this chapter ● ● ●

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Outlining the difference between clinical supervision, mentoring, and leadership. The difference between clinical supervision and case management supervision for low-intensity practitioners. To consider the impact on fitness to practice where the opportunity for restorative supervision is not factored into case management or group clinical skills. Generating discussion and thinking around proposed changes to low-intensity psychological therapy supervision.

Functions and use of supervision in the psychological professions Clinical supervision in the broader field of counselling and psychotherapy is a professional interaction where a clinical supervisor is typically either more qualified or experienced (often both) in a particular discipline or profession than their supervisee (Bernard and Goodyear, 2004). The overarching functions of supervision should be educational (learning and development as a clinician), restorative (a space to process the impact of clinical material and interactions), and quality assurance (safety and protection of the patient), as well as monitoring competencies in a professional psychotherapeutic modality (Gale, 2016; Scaife, 2019). Clinical supervision is also vital to supporting consultation, reflection, standards, and quality of care for patients across teams (BPS, 2017). Where the primary role of a clinical supervisor is within an organisation offering psychotherapy and counselling, there is also likely to be a stronger focus on issues arising between the practitioner and patient in terms of therapeutic processes, including the requirement for inward self-reflection and evaluation for both the supervisor and supervisee. Clinical supervision also needs to have boundaries within a professional clinical context and should not be utilised as a substitute for either personal therapy or personal relationships and friendships (Watkins, 2011). This distinction is important as problems and challenges will naturally arise and need to be addressed practically and objectively and may also include process or technical issues involving the supervisory relationship, which may lead to wider problems or consequences for both the clinician and the patient, if avoided (Watkins, 2011). Therefore, variation in the formality of the relationship during supervision may be required (Scaife, 2019), particularly where this is undertaken by close work colleagues.

Line management versus clinical supervision Direct line management activities, for example, caseload allocation and management, outcome monitoring, and performancerelated feedback, including clinical contact hours, or timekeeping, should be separated from the functions and purpose of clinical supervision. This can pose potential logistical challenges within busy mainstream services such as the IAPT programme. Whilst every attempt should be made to keep line management and clinical supervision separate, there will likely be occasions where these may end up being undertaken by the same person. Essentially, this would confer what is referred to as a dual relationship (BPS, 2017) and would require contracting and containing the different purposes and functions of line management versus clinical supervision. For example, the expectations of both the supervisor and supervisee, distribution of responsibility, learning and feedback style most likely to support the process, and consider the most suitable model of supervision that meets the needs of all concerned, including the client group and service configuration (Scaife, 2019).

Care in High Volume. https://doi.org/10.1016/B978-0-323-88492-1.00010-5 Copyright © 2023 Elsevier Inc. All rights reserved.

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Mentoring versus clinical supervision Mentoring is the intentional activity of supporting someone to increase their agency over a particular area of learning or development. This can relate to personal or professional performance, aims, and goals (Parsloe and Leedham, 2016, p. 35). Atkinson et al. (1994) described the differences between clinical supervision and mentoring as, [mentoring] proactively seeks to enhance the development and education of a protégé [mentee] whilst a traditional supervisor or advisor only promotes the development and education of a supervisee to the extent demanded by their position (p. 39).

Essentially, the more senior or advanced professional experience that is commonly demonstrated when supervising others does not apply when mentoring. Mentoring can be undertaken by peers as well as less experienced members of staff. For example, a senior psychotherapist may wish to enhance their skills in academic writing, and a person from a different profession or role, including more junior staff members who have developed skills or experience in academic writing, would be able to mentor the senior staff member, but would not supervise them clinically. The benefits of mentoring across different professional disciplines have been shown to increase productivity and networking within and across teams, including increased reporting of satisfaction and commitment at work (Wanberg et al., 2003). Mentoring can also include interpersonal components similar to those of the common factor skills in therapeutic work, such as active and attentive listening (Parsloe and Leedham, 2016) and authenticity (Stokes, 2003). Again, whilst mentoring cannot act as a substitute for personal therapy or friendships, it can be potentially useful to increase and enhance productivity, and the achievement of performance targets within teams, as well as supporting staff wellbeing and retention. Mentoring can also facilitate beneficial outcomes for diversity and inclusion within professional disciplines and teams (Chan et al., 2015).

Leadership versus line management Leadership is the ability to influence, demonstrate, and model processes, concepts, and ideas that are potentially beneficial and in the shared interests of a wider group or team. For example, where individuals or groups exhibit positive novel or enhanced actions in the wider interest of their groups, services, systems, and organisations (Platow et al., 2017). Leadership can be demonstrated by anyone within a team, organisation, or system, regardless of their role, status, or qualification level. The NHS Healthcare Leadership Model (2013) provides a framework to support individuals and groups to inspire and influence others, and develop their capabilities, whilst also holding onto the importance of being connected to others, and engaging with people and systems compassionately and with care (NHS, 2013, p. 4). Here, leadership is separated from ‘line management’ (the active processes of ensuring adherence and compliance to policy and practice; Gale, 2016), clinical supervision (more senior or experienced clinicians helping to support and develop clinical competencies) and mentoring (anyone who has valued experience and competency to support someone else to achieve their aims and goals).

Monitoring fitness to practice Clinical supervisors and line managers also have a professional obligation to address concerns relating to the clinician’s competency and ability to work safely with patients (BPS, 2017 p. 65). This includes interpersonal competency, risk assessment and safety planning, working within the scope of training and qualification, and monitoring and managing personal wellbeing, including burnout. Of note here, particularly relating to the high-volume caseloads that commonly include people presenting with dynamic risk factors, complicated social contexts, and varying degrees of severity of reported distress, it is vitally important that fitness to practice is carefully monitored in IAPT services to ensure patient and clinician safety.

Case management versus clinical supervision As with any psychotherapeutic modality, supervision, mentoring, line management and leadership and monitoring of fitness to practice are equally fundamental to low-intensity psychological therapy. However, individual low-intensity supervision is typically called (and more accurately described as) ‘case management’. Case management serves the purpose that it alludes to on the tin, essentially managing and monitoring clinical cases in line with the IAPT standards on access, outcome, and waiting times. A brief summary outlining the current requirements for low-intensity practitioners to fulfil when attending individual weekly clinical case management, adapted from Richards and Whyte (2011): 1. All new patients presenting on your caseload, including a discussion of demographic and background information relating to new treatment or assessment appointments. 2. Each assigned case should be discussed at regular intervals, no less than every fourth week/session.



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3. Any patients presenting with risk should be discussed as a priority. 4. Any patients whose scores exceed predetermined thresholds for low-intensity psychological therapy. 5. Any outstanding sessions, missed, or overdue appointments. 6. Any patients where you are seeking support or advice. This includes stepping decisions, for example, whether the patient is presenting with a problem that is likely to be successfully treated with low-intensity intervention, or whether a higher intensity of treatment or alternative service is required, progress reviews and outcome monitoring (whether the person’s scores are reducing on the measures of depression and anxiety), discharge, and risk reviews. However, given the typical nature of low-intensity work that we have outlined in this book, there is very little time to attend to the restorative and process-based elements of low-intensity clinical practice. The IAPT standards that drive the processes of case management in line with key performance indicators (KPIs), are:

Target 1: Access IAPT services are expected to offer appointments to a predetermined percentage of the population who are statistically likely to have depression or anxiety, for example, if 25% of the population of the country is likely to have a common mental health difficulty, then IAPT would be expected to see a percentage of that 25%. The value of that percentage is currently rising year on year. In 2011 the target was for 15% of the population with depression and anxiety to access IAPT, this year IAPT is expected to see 25% of the population who have common mental health problems. The diagram in Fig. 10.1 shows a breakdown of what percentage of people who access psychological therapies in a stepped care model were expected to access. If these still apply, then low-intensity practitioners in IAPT are trying to provide a service for 2.2 million people this year.

FIG.  10.1  The breakdown of people accessing psychologcial therapies servies in England. The breakdown of people accessing psychologcial therapies servies in England. (Adapted from National Institute for Health and Clinical Excellence, 2011. Guidelines CMG41: Commissioning Stepped Care for People With Common Mental Health Disorders. Available at: https://mentalhealthpartnerships.com/resource/ commissioning-stepped-care-for-people-with-common-mental-health-disorders-cmg41/.)

Target 2: Waiting times The second IAPT standard is an expectation that people will be assessed and start treatment within a certain time frame. Overall, 95% of people who come to IAPT for treatment should start treatment within 18 weeks, and 75% of people who come to IAPT should be in treatment within 6 weeks. So, with back-of-the-envelope maths, we’re looking for a quarter of a million people to enter IAPT treatment every 6 weeks. Since low-intensity practitioners are the first point of entry into the stepped care system, the majority of those people will need an appointment with a low-intensity practitioner.

Target 3: Recovery The recovery target is linked to the idea that we can produce results in live practice that match those produced in clinical trials. Essentially, 50% of the people who have a course of treatment in IAPT (treatment is defined as two or more appointments) are expected to report ‘recovery’ on the clinical outcome questionnaires that we use at every session. For the ­recovery

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target, the questionnaires that matter are the PHQ-9 for Depression and GAD-7 for generalised anxiety, with other more specific measures available for panic, OCD, health anxiety, PTSD, generalised anxiety disorder, and social anxiety disorder. Provided that low-intensity practitioners are working with straightforward mild to moderate cases of anxiety and depression where only simple reviews are necessary, where there are few complicating or problematic interpersonal factors, then a system of case management, as opposed to clinical supervision, can potentially work in theory. However, based on an average of 1 h per week of case management supervision for a full-time equivalent low-intensity practitioner, it is common that they will have literally minutes to discuss each of their cases. This often leaves little to no room for an in-depth discussion about patient difficulties or for the restorative elements of supervision that are crucial to support the wellbeing of the clinician and to help the clinician explore the potential challenges and difficulties that the patient may be experiencing in implementing change.

The function of high-volume case management: Supervision versus leadership The following outline of the core clinical functions of low-intensity case management is based on Bennett-Levy et al. (2010). 1. Fidelity to evidence-based practice: This is to ensure that IAPT is implementing NICE-recommended interventions, providing patients with interventions that have a reasonable chance of being effective and not following practitioner instinct and preferences. 2. Clinical governance: This is to ensure that the right intervention is offered to the right person, in the right way, at the right time, by somebody with adequate qualifications. 3. Patient safety: This recognises the likelihood of high drop-out rates and ensures that patients who do not continue with treatment are reviewed and that their risk and safety have been considered. 4. Clinical decision-making. This recognises that low-intensity practitioners work within a stepped care system and supervision that take account of the clinical outcome data can ensure that the most appropriate care is recommended. This is also intended to prevent practitioners from developing bad habits in their clinical practice and ensures that no cases are missed during supervision. Ultimately, the task of a low-intensity supervisor is not only to oversee the risk, safety, and efficacy of the supervisee but they are often tasked, whether directly or indirectly, to monitor and review the supervisee’s recovery outcomes, caseload, and access targets to support the wider service to achieve their KPIs. Here, low-intensity supervision moves away from the concept of clinical supervision as is typical in the wider profession of counselling and psychotherapy and leans more towards line management as opposed to either clinical supervision, mentoring, or leadership. In our personal experience of the reality of clinical practice as low-intensity practitioners and supervisors, and as we have described in detail throughout this book, low-intensity caseloads are typically far from low, simple, or straightforward. Also, interpersonal processes are typically poorly understood with no formal training or model to address issues where these arise. Add to this that the review of someone’s clinical practice, including where problems are being fed back, as well as clinical work that has affected the practitioner personally, can often be heavily time-bound and adjunct to the tasks of managing risk and targets, and is therefore insufficient to meet the broader needs of the low-intensity practitioner.

Clinical skills groups In addition to individual case management, low-intensity practitioners in the IAPT programme should attend a clinical skills development group for at least 2 h per month (NCCMH, 2021). Skills groups are recommended not to exceed 12 practitioners at a time, which from our perspective would still be far too many and would significantly limit the opportunity of all participants involved. We would recommend a cap of an absolute maximum of eight practitioners at any time in a clinical skills group. The skills groups are (more often than not) facilitated by a qualified low-intensity supervisor who has undertaken specific training at a university as part of the IAPT supervision programme. Clinical skills development will typically cover different topics, such as developing and deepening knowledge of the interventions, discussing challenging clinical work, and sharing best practice. Our experience with low-intensity clinical groups has been varied. Some have offered reflective spaces to discuss deeper issues relating to clinical material, others less so, and lean more towards peer support and group-based mentorship.

Contextualising the low-intensity supervisory model in England A low-intensity practitioner who is employed on a full-time basis in NHS services is currently recommended to undertake around 20 h of clinical contact time per week (NCCMH, 2021), but the interpretation of this guidance can vary significantly



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from service to service. In some services, practitioners are asked to undertake no more than six clinical contacts per day, balancing 60-min assessments and 30-min treatment sessions across a 5-day week. In our opinion, this is a healthy number of contacts and conducive to safe and ethical practice. In the majority of services, the clinical contact is between 8 and 10 contacts per day. However, in a few of the services operating with IAPT funding, we have been aware of practitioners (including trainees) where expected daily clinical contacts are 12 per day (yes, you read that right, 12). This, in our opinion, would be conducive to unsafe and unethical practice, particularly where this is more likely to lead to poor staff wellbeing and burnout, and subsequently an increased likelihood of problems leading to fitness to practice concerns. One of the common reasons cited by service managers when justifying such large numbers of daily contacts, is, on the one hand, to incorporate additional time to make up for potential non-attended (DNA) appointments. The justification here is that the average daily contact becomes eight per day if four patients do not attend. On the other hand, an average total of 20 h per week of clinical time delivered is in line with the broader counselling and psychotherapy modalities. The difference here is that counsellors or psychotherapists delivering 20 h of clinical contact per week will typically see 20 patients, given their sessions are commonly based on the therapeutic hour (commonly 50 min). If they are asked to book a further 4 h per week of clinical contact to allow for DNA appointments, the maximum number of potential patients is 24 per week. For low-intensity practitioners, particularly those offering 12 patient appointments per day, and up to 24 h of clinical contact time per week as full-time members of staff, are also commonly asked to offer triage assessment appointments lasting up to only 30 min. Treatment sessions also last 30 min in addition to this. Essentially, 12 patients per day, each with a 30-min appointment, over 4 days of clinical contact with 1 day per week for administration, equates to 24 h of clinical contact per week. Given that it is also common in IAPT services for low-intensity practitioners to offer fortnightly treatment schedules, this then potentially doubles the number of people they take on for treatment. Therefore, a low-intensity practitioner operating with 12 patient contacts per day could potentially be working with 48 different individual patients per week based on 24 h of clinical contact. This means they will also be holding a clinical caseload in the range of 60 to 90 patients per practitioner, many of those patients who are neither presenting with mild to moderate problems or low-risk factors. Those ‘high-volume’ caseloads then become very high-volume, and not so low-intensity. In our opinion, both the current model of skills groups and case management supervision, contextualised within the clinical reality (as opposed to the academic literature) of a typical low-intensity caseload, is neither safe nor effective in current practice.

Variation within the current model of low-intensity supervision As supervisors, we have worked with a broad range of practitioners, from trainees to qualified, and senior qualified practitioners across different IAPT services in different parts of the country. Some supervision sessions might incorporate indepth discussions of four to eight patients, and depending on the practitioner facilitating the supervision session, there is sometimes room to discuss the impact of the clinical work with a greater focus on reflective practice. However, it is more the norm in IAPT services that clinical case management will be quite pressured, often where upward of 15 to 20 cases are being reviewed, with any cases involving risk, taking priority and any additional time required to then support the practitioner with the impact of difficult patient sessions will typically be done in the practitioner’s own time. In some cases, assessment sessions are reviewed and supervised remotely through electronic systems without any face-to-face or telephone discussion, leaving case management supervision to focus specifically on treatment cases, albeit with a primary focus on stepping and discharge decisions, as well as session extension requests.

Further challenges with the current model of low-intensity supervision Practitioner attrition is a mammoth problem in IAPT services, particularly at low intensity, and it is not uncommon to find only a handful of seasoned qualified low-intensity practitioners who have more than 2 years of experience in some services. At the time of writing, three IAPT services local to us have literally no qualified low-intensity practitioners and are currently operating their low-intensity arm purely on trainees. Due to the requirements of regular case management supervision and a high turnover of staff, it is not unheard of in very pressured services to find recently qualified practitioners to be delivering case management supervision (whether they have completed the university training course as a low-intensity supervisor to do this, or not). In one particular service that we are aware of, two practitioners are supervising more experienced staff in their service, after only 6 months of qualifying as a low-intensity practitioner themselves. Whilst there is often a focus on academic literature when low-intensity supervision is discussed in training manuals and training course material, ‘what it is and how to use it effectively’, these rarely describe the ongoing problems and limitations with the current model when contextualised within the reality of the role.

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When we talk about low-intensity clinical supervision, this is not supervision as it is commonly practiced in the broader psychological professions and technically would be somewhat of a stretch to actually call it clinical supervision. In reality, it is more of a crossover between line management and mentoring. What is also less considered is that there are many practitioners within the IAPT programme who hold intersectional differences in their identity. Where in the current model of low-intensity supervision is there space and time amongst 15 to 20 cases of moderate to severe depression and risk assessment reviews, for a discussion to happen where a practitioner might have experienced racism, homophobia, transphobia, or disability discrimination within a patient session? More importantly, as low-intensity supervisors, who has the experience, training, and knowledge to facilitate this?

Is the current low-intensity supervisory model fit for purpose? At the risk of speaking on behalf of the English low-intensity profession, the short answer here, in our opinion, is no. Although its function is sufficient to monitor patient risk and safety in terms of what the low-intensity practitioner role was originally intended to do, it was also designed to support a stepped and target-oriented system of healthcare, rather than the clinician and the patient. In light of the reality of what the role has become, and with around 14 year’s worth of low-intensity practitioners constantly leaving the role, constantly burning out, high drop-out rates from patients accessing the services, and low-intensity practitioners constantly saying the same things about the shortfalls in their opportunity for deeper level supervision, it is our opinion that the current model simply does not meet the wider needs of the current workforce.

So what do we do about the current challenges with supervision? This is not an easy question to answer and is likely to be a longer and more protracted discussion amongst the services in the IAPT programme, university training courses, and the IAPT national team. Our personal thoughts here, and to extend on what James wrote about in Chapter 9, Reflecting on Interpersonal Practice, is that interpersonal competencies are both a vital requirement of the skill set of the low-intensity practitioner, and these take time to develop, requiring observation of clinical recording, the building of relationships, and both the supervisor and supervisee to hold a capacity and will for deeper inward reflection. This is hard to do when the practitioner has an average of 3 min per patient during case management supervision, or when they are sitting in a group learning how to enhance a behavioural activation diary. Also, we need to be mindful that we cannot ask practitioners to consent to invasive deep dives into their history nor can it turn into a pseudo-therapy session. Therefore, we require some way of utilising a model that can support the concepts, but without practitioners attempting to supervise beyond their scope of knowledge and training, or potentially psychologically harming their supervisees.

Supervision contracts An essential tool here is the supervisory contract. It is very common to see supervisors starting out with their supervisees with a standard template supervision contract from the service and changing or adding very little to it. Obviously, in fastpaced services where there is limited time to review this, it can be easily overlooked. Wherever possible it is important to outline to our supervisees (particularly qualified low-intensity practitioners) that the supervision contract is a working document, requiring regular review, should be collaboratively agreed and should also specifically outline any learning needs, including adjustments or adaptations, where required. We would also recommend that a discussion should take place initially about how the supervisor and supervisee might agree on giving difficult feedback, particularly when it comes to discussing capabilities in relation to interpersonal competency and the delivery of clinical interventions. This way, each person is clear on what they need from the supervision sessions and the contract can be referred back to/reviewed/updated if problems arise. Equally, it also important to contract (whether verbally or in writing) not only how feedback is to be given but also what the supervisee (or supervisor) might anticipate if they receive criticism, and how they might want to discuss or manage this, what they perhaps would want to be reminded of if difficulties persist. Also, and is a vital part of contracting with supervisees in terms of monitoring interpersonal competencies, is to encourage supervision as a safe and non-judgmental space and to bring experiences of sessions that are going well, and not so well. Clearly stating the purpose of feedback in low-intensity supervision is to enhance existing skills, not to rip them apart and destroy someone’s confidence. Again, as with patients, for some, this will be the expectation and experience of the supervisee, regardless of how sensitively or diplomatically you feed back.



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Recording sessions We would also encourage practitioners, whether training, qualified, or in senior positions to regularly record their clinical sessions, regardless of whether this is for university submission during training or not. This is also something that is recommended in the national IAPT guidance and is a great way to self-monitor and learn. It is important to note here that in the United Kingdom, patients are freely able to record their clinical sessions without the consent or permission of the clinician. However, clinicians are not permitted to record without the patient’s expressed consent and permission, which can be withdrawn at any time. For a practitioner to record a clinical session, this requires signed (written or electronic) consent from the patient as well as verbal consent. Clinical recordings must be stored on a secure and encrypted device and are considered electronically stored confidential information under General Data Protection Regulation (GDPR). Most practitioners tend to be a little bit squeamish at the thought of recording clinical sessions and commonly avoid recording, unless this is essential for university purposes, often stating that the patient has declined the consent to record. Yet, more often relating to the practitioner having tentatively approached the subject as opposed to asking directly and explaining the reason for this being to enhance practice and the intervention for the patient (as opposed to scrutinising the practitioner and trying to catch them out). In most cases, if we explain to our patients that we record sessions in order for the supervisor to help the practitioner to help the patient, rarely do patients not accept the additional help. In fact, our experience is that recording sessions is helpful to both the patient and practitioner, and both tend to forget the session is being recorded once they get used to doing it. Albeit, some people do not want to be on video and often prefer audio recording or the camera pointing at the practitioner, either is fine. Of course, should a patient genuinely not wish to be recorded, they should never be forced or coerced.

Upscaling the current model of low-intensity supervision Another part of the problem here is that supervisors themselves (as humans) can also lack awareness of their own interpersonal processes, including (as with the case between patients and practitioners) where their processes are very similar (and therefore blind to), those of their supervisee. How can an objective middle ground be found on which to consider the clinical interaction with the patient, then? Similarly, it is not uncommon to hear of supervisors who heavily personalise the work with their trainees. For example, where problems have occurred with a clinical session recording and feedback is offered to the trainee through a university marking team, for the supervisor to then become overly involved in disputing the feedback, perhaps where they have offered extensive feedback to the trainee prior to submission, and this does not match what is observed and interpreted by the university marking team. This can be very challenging to navigate and has happened to both of us on more than one occasion. Naturally, there may be occasions where the feedback feels unjust or unfair, and it is very reasonable to want to open a discussion about that, particularly where different universities may interpret the guidance in different ways. Common human stuff. But how we manage our relationships here, again, often involves complex interpersonal processes when managing difficult feelings whilst also trying to hold different positions in our minds, including the relationship between supervisors and their trainees, and have room to reflect on what is happening and why it is happening. The importance of this is that if you have a trainee practitioner who does not respond well to feedback, is avoidant, controlling, or heavily defensive, and you have a supervisor that is keen to please and afraid to upset or challenge the supervisee or gets tangled up with similar processes themselves, then you have a pretty concerning problem when it comes to the clinical work of the trainee, that, as a supervisor, you are accountable for during their training period. And, as we have outlined before, can also lead to problems in our wider professional relationships leading to fitness to practice issues. It is very important that we do not become blind to problems by becoming overly involved with our supervisees.

Implementing low-intensity clinical supervision One of the models that we are suggesting as a way to move forward is the seven-eyed model of supervision (Hawkins and Shohet, 2006). Briefly, this model approaches supervision through two interconnected systems; the supervisee and the client, and the supervisee and the supervisor (Fig. 10.2). The ‘seven eyes’ of the model focus on specific components of the supervisory process: Patient and the practitioner 1. How does the patient present in the session? What things do they talk about? Are there key themes and content? How does this link to other sessions, aims, and goals? How does this translate to the person’s life?

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FIG. 10.2  Seven-eyed model of supervision. (Adapted from Hawkins, P., Shohet, R., 2006. Supervision in the Helping Profession, third ed. McGraw-Hill Open University Press, Maidenhead.)

2. What are the techniques and interventions being used by the supervisee? Have alternative options been explored that may be more appropriate to the patient's aims and goals? 3. What is happening in the relationship between the patient and practitioner? Is there evidence of a good working alliance? How does the patient respond to the practitioner? What is the practitioner’s own perspective? Supervisee and supervisor: 4. Has the supervisee been affected by their work with the patient? What are their thoughts and emotions when talking about the patient? What support might they need? What development needs might they have or have identified for the future? 5. What is happening in the supervisory relationship? Are there signs of a good working alliance? Are there problems or ruptures? How might we understand this in the context of parallel processes in the patient and practitioner relationship? 6. What are the supervisor’s own thoughts, emotions, and reactions to the way the patient is described by the supervisee? What information might this give us about what is happening for the patient? 7. What is the wider context of the system? How might this relate to professional ethics and organisational barriers or restrictions? Whilst a more in-depth focus on the relationship dynamics between the patient, the supervisee, and the supervisor leans more towards a relational model of supervision, it could likely easily be adapted to consider the practicalities and core competencies of the low-intensity remit. What might be required however is that this aspect of supervision is done in addition to the current format that is adopted more broadly in low-intensity supervision across the IAPT programme. Due to the high-volume nature of the work, case management supervision will very likely be required to take place at its current level, yet, perhaps there is room to adopt a mix of group-based clinical skills and individual supervision focused on interpersonal skills, or even better, 1 h per month individual supervision on top of what is currently offered, ring-fenced to discuss the impact of clinical work, listen to session recordings, and provide space for more in-depth discussion around challenging or complicated cases. Ultimately, low-intensity psychological practitioners have had to adapt and shift considerably since the role’s early inception in order to meet the needs and demands of local populations. Yet, the systems and processes designed around its original concept have failed to move at the same pace, in most cases, have not adapted and shifted at all. If we are to progress the low-intensity role, its efficacy, range of intervention, and develop as a psychotherapeutic approach in its own right, then this needs to be matched with adequate and sufficient clinical support to ensure safety and competency.



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References Atkinson, D.R., Casas, A., Neville, H., 1994. Ethnic minority psychologists: whom they mentor and benefits they derive from the process. J. Multicult. Couns. Dev. 22 (1), 37–48. Bennett-Levy, J., Richards, D., Farrand, P., Christensen, H., Griffiths, K., Kavanagh, D., et  al. (Eds.), 2010. Oxford Guide to Low Intensity CBT Interventions. OUP Oxford. Bernard, J., Goodyear, S., 2004. Fundamentals of Clinical Supervision, third ed. Pearson Education, Boston. British Psychological Society, 2017. BPS Practice Guidelines. Available at: https://www.bps.org.uk/guideline/bps-practice-guidelines-2017-0. Chan, A.W., Yeh, C.J., Krumboltz, J.D., 2015. Mentoring ethnic minority counseling and clinical psychology students: a multicultural, ecological, and relational model. J. Couns. Psychol. 62 (4), 592. Gale, N., 2016. Leading and managing. In: Douglas, B., Woolfe, R., Strawbridge, S., Kasket, E., Galbraith, V. (Eds.), The Handbook of Counselling Psychology. Sage, London, pp. 567–582. Hawkins, P., Shohet, R., 2006. Supervision in the Helping Profession, third ed. McGraw-Hill Open University Press, Maidenhead. National Collaborating Centre for Mental Health, 2021. The Improving Access to Psychological Therapies Manual. Available at: https://www.england. nhs.uk/wp-content/uploads/2018/06/the-iapt-manual-v5.pdf. NHS Leadership Academy, 2013. The Healthcare Leadership Model, Version 1.0. NHS Leadership Academy, Leeds. Retrieved from https://www.leadershipacademy.nhs.uk/resources/healthcare-leadership-model/. Parsloe, E., Leedham, M., 2016. Coaching and Mentoring: Practical Techniques for Developing Learning and Performance. Kogan Page, London. Platow, M., Haslow, A., Reicher, S., 2017. The social psychology of leadership. In: Harkins, S., Williams, K., Burger, J. (Eds.), The Oxford Handbook of Social Influence. Oxford University Press, USA, pp. 339–360. Richards, D., Whyte, M., 2011. Reach Out: National Programme Student Materials to Support the Delivery of Training for Psychological Practitioners Delivering Low Intensity Interventions, third ed. Rethink Mental Illness. Scaife, J., 2019. Supervision in Clinical Practice. A Practitioner’s Guide. Bruner-Routledge, Hove. Stokes, P., 2003. Exploring the relationship between mentoring and counselling. Br. J. Guid. Couns. 31 (1), 25–38. Wanberg, C.R., Welsh, E.T., Hezlett, S.A., 2003. Mentoring research: a review and dynamic process model. Res. Pers. Hum. Resour. Manag., 39–124. Watkins, C.E., 2011. Does psychotherapy supervision contribute to patients’ outcomes: thirty years of research. Clin. Superv. 30 (2), 235–256.

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Chapter 11

Professional identity Elizabeth Ruth University of Bradford, Bradford, United Kingdom

Learning aims for this chapter This chapter will consider the professional status of low-intensity psychological practitioners. Starting with a discussion of the current job titles that are offered to practitioners of this approach, we go on to think about how the current skills and duties held by these practitioners meet the standards for professional recognition. This chapter acknowledges the interprofessional dynamics in a stepped care system and considers the issue of staff retention and workforce stability in the context of professional identity. Asking: ● ● ●

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How do you sustain a workforce that can be perceived as least qualified and experienced? How can equality between the modalities that are offered in a stepped care system be promoted? How can the variety of skills and qualities that low-intensity clinical practice inculcates be recognised and harnessed as a powerful and effective resource in mental healthcare teams? How can we mitigate the perception of low power and value that is sometimes attached to the low-intensity roles and promote retention in the role to improve its sustainability?

Despite an intensive decade and more of implementation and development in low-intensity psychological interventions, we still haven’t got universal definitions of what we do and who we are. Low-intensity psychological interventions have a lot to offer to the patients who access them and the healthcare systems that support them, but our professional status is still in doubt and too often it is academics and practitioners of other modalities who make decisions on our behalf and produce the body of literature about us. I am going to start by offering some definitions of what low-intensity psychological interventions are and the language used to describe the practitioners of this approach. We’ll consider why professional status matters, and what it requires from practitioners, then going into IAPT where I’ll share some experience of how the role of low-intensity psychological practitioner works in a team dynamic with other professions before finally thinking about what all of this means for retention of the workforce. As usual I’ll make clear the proviso that the authors of this book have practised low-intensity psychological interventions exclusively in an IAPT context, offering care to adults who experience depression and common anxiety disorders. We can’t speak authoritatively about the other areas of low-intensity interventions development. Despite the limitations of the authors, it’s important to recognise that a collective sense of self is emerging across the low-intensity professions in the context of multiprofessional teams. The comparative wealth of the various psychological professions impacts on the wellbeing of low-intensity psychological practitioners, retention in the role, and the long-term sustainability of low-intensity practitioner (or Wellbeing Practitioner, as some would prefer. Final designation TBD…) as a distinct professional identity. I hope to offer ideas for the future that will support a robust professional identity, aid staff retention in these roles, and give low-intensity interventions the liberty that the approach needs to translate into new settings.

The tug of war Like I said in Chapter 1, the low-intensity psychological practitioner role developed to supply minimum safe healthcare staff contact to deliver supported self-help or supported self-management for common mental health disorders. We offer assessment of depression and anxiety disorders and deliver a limited number of evidence-based interventions, drawing on

Care in High Volume. https://doi.org/10.1016/B978-0-323-88492-1.00011-7 Copyright © 2023 Elsevier Inc. All rights reserved.

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a number of different theoretical models to do so. The practitioners who work in this approach have been called all sorts of things, ‘case managers’, “semiprofessionals’, or ‘junior mental health workers’, to take a few random examples from various research papers published over the last 15 years. The Psychological Professions Network (a bit more about them later) in England now recognise low-intensity practitioners amongst the psychological professions. Two regulating bodies offer practitioner registration for IAPT psychological wellbeing practitioners and the promise of registration for the other low-intensity professions. Registration comes with accountability to a code of professional conduct, ethics, and standards of practice that have to be upheld. Registration also provides more opportunities to develop a community of practice that will enable development of the approach from within, by the practitioners who deliver it. Even with all of this, we still haven’t reached a consensus on the language that is used to describe this way of working and the people who do it. A label of ‘Wellbeing Practitioners’ is emerging as an umbrella term to describe psychological practitioners who deliver low-intensity psychological interventions. This would include ‘Psychological Wellbeing Practitioners’ who deliver low-intensity psychological interventions for adults with depression and anxiety, typically in IAPT services. ‘Children and Young People’s (known as CYWP or CWP) Practitioners’ who deliver low-intensity psychological interventions in Child and Adolescent Mental Health multidisciplinary teams, and ‘Educational Wellbeing Practitioners’ (or EMHPs) who deliver low-intensity psychological interventions in schools and colleges. The newest member of the gang is the ‘Mental Health Wellbeing Practitioner’ (MHWPs) who deliver ‘wellbeing-focused psychologically informed interventions’ (as described in the tender notice from Health Education England) as part of integrated teams who support people with severe and enduring mental health conditions. Job titles: A blogger’s lament Personally, I have never liked the job title ‘Psychological Wellbeing Practitioner’ and would move us away from it as quickly as possible if I had the power to do so. I wrote a whole blog post about this in 2019 and most of what I said then still stands: Whenever I hear my full job title I imagine someone in London, or certainly down south, spitballing ideas onto a flip chart in a meeting to try and impress someone, and everyone in the room being fed up and/or hungover and/or ready for lunch and going—‘yep that’s good enough, lets eat’. I, and most of my colleagues, can’t stand this job title/name for our emerging profession. It’s twelve syllables for crying out loud. Twelve! How is a patient supposed to make sense of that or remember it? Most of the people in my area have a reading age of 7, they can’t even read my job title. How do you abbreviate it? PWP sounds like ‘poop’ if you try to say it as a word. Or like a baby owl with a speech impediment at best. It’s meaningless and confusing.

Slightly more generously I can see the sense in combining ‘psychology’ and ‘wellbeing’ in the description for what we do—they are kind of central to the whole gig. I’m sure, in all seriousness, that a lot of thought went into it. I’m just not sure it translates very well into typical English usage in most of the country. Then try helping people to understand what you do in a city with more than 20 spoken languages, and you can see my problem. …[at a Low Intensity CBT event hosted by the British Association of Cognitive and Behavioural Therapists in 2019] Liz Kell, amongst other excellent ideas about how we could mature as a profession, pointed out that the Psychological Wellbeing Practitioner (PWP) appears in England, but Low Intensity Therapists (LIT from now on) are worldwide. Obviously I write about the context in IAPT services in England, and officially my job title is PWP, but hopefully enough of this experience will translate to other Low Intensity settings that using Low Intensity Therapist for all of us will make sense….

Some outside support As you can see in 2019, a couple of us were moving towards ‘low-intensity therapist’ as a useful descriptor for practitioners of this approach. We’ve all back-pedalled away from the use of the word ‘therapist’ now—I’ll say more about why later in this chapter—and lean towards ‘Practitioner’ as being more accurate and descriptive of what we do. There are still academics out there who would be much happier to use ‘coach’ to describe us, but I’m not going to dignify that with anything more than my best ‘angry librarian’ glare over the top of my glasses. I’ve said this elsewhere in this book, but I’ll repeat: There is, and always has been, a chasm between how we are represented in the available literature and how we describe and identify ourselves as practitioners of an emerging profession. A helpful development that got off the ground in 2018 is the emergence of the Psychological Professions Network (The PPN); from their website in April 2022, the PPN describes itself like this: The Psychological Professions Network is a membership network for all psychological professionals and other stakeholders in NHS commissioned psychological healthcare. We are commissioned by Health Education England to provide a joined-up voice for the psychological professions in workforce planning and development, and to support excellence in practice.



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They are relatively new on the scene with a stated goal of embedding psychological knowledge in all aspects of health and social care provision. The PPN came out of the gate swinging in recognition of the value of low-intensity interventions and practitioners. Their video ‘PPN Who are the 12 Psychological Professions? (with career map link)’ was uploaded to YouTube in April 2020 https://www.youtube.com/watch?v=7Zya-NAQq2Y and places Psychological Wellbeing Practitioners, Children’s Wellbeing Practitioner, and Educational Mental Health Practitioner (all roles whose function is to deliver low-intensity psychological interventions) alongside other psychological professions, emphasising the ‘different but equally valuable’ mantra that really ought to be (but too often isn’t) common sense wherever psychological therapies are delivered. In 2022, the new Mental Health Wellbeing Practitioner role has been added to the cohort of low-intensity practitioners. Although the PPN does great work, their advocacy of low-intensity practitioners is not felt as strongly in the other Home Nations of the United Kingdom (Northern Ireland, Scotland and Wales). We have to look to our registering bodies—the British Psychological Society and the British Association of Cognitive and Behavioural Psychotherapists to hold us all together and that is an ongoing piece of work. The PPN is where the umbrella term ‘Wellbeing Practitioners’ comes from, and it feels almost ungrateful to disagree with them about terminology when they have done so much to give us equal recognition amongst the psychological professions. I’m still going to do it though. What has emerged, in my observation, is a sense that job titles like ‘Psychological Wellbeing Practitioner’ are so generic as to be practically useless. This was starkly apparent when several services in the country of Wales advertised ‘Psychological Wellbeing Practitioner’ job posts without any requirement for applicants to have completed an accredited training programme or to work within a specific model and method. Those posts were more akin to what would be support worker or assistant psychologist posts in England. The implementation of registers for Psychological Wellbeing Practitioners in England offers patients some protection and assurance about what they will be offered by psychological practitioners with that job title, but not enough. You can’t really protect words like ‘wellbeing’ and ‘practitioner’ and make them universally meaningful. Job titles should unambiguously communicate the function of the role to the recipient of care and to other professionals. So we’ve got a bit more work to do on definitions and job titles. In Scotland, ‘Enhanced Psychological Practitioners’ are being trained to the same curriculum that we use for Psychological Wellbeing Practitioners in England. ‘Enhanced’ psychological practice does not provide the clarity that we need in a job title, but it is more appealing and less demeaning than ‘low intensity’. Who knows, the next time a book on this topic is published we might have replaced ‘low intensity’ with ‘enhanced’, and we would probably be the better for it.

Describing an umbrella In 2021, a group led by Professor Roz Shafran attempted to provide a definition of ‘Low-Intensity Cognitive Behavioural Therapy’. Their paper ‘The concept and definition of cognitive behaviour therapy’ is probably the most respectful and useful piece written on this topic, and it makes helpful distinctions between ‘standard CBT’, ‘brief CBT’, and ‘low-intensity CBT’. Think-pieces like this are a great start but, from my perspective, are not sufficient to reach agreed definitions of the Low-Intensity Psychological Interventions and professional identities that have emerged in the last few years. In the 2022 World Mental Health Report, transforming mental health for all the World Health Organisation emphasises the need to scale up provision of psychological care services. They describe ‘nonspecialist counselling’ delivering evidence-based interventions, and guided self-help separately as options to increase service provision. From the text in the report, I suggest that both of these options could be as follows.

Not just CBT As a course leader on an accredited Low-Intensity IAPT training programme, I teach low-intensity CBT-informed interventions to trainees who are employed in IAPT teams, and I always draw attention to the difference between ‘low-intensity CBT’ and ‘low-intensity psychological interventions’. What PWPs deliver in IAPT low-intensity CBT because that is what NICE guidelines recommend for patients with depression and some anxiety disorders. However, what IAPT delivers is not the entirety of the low-intensity psychological interventions approach, just one facet of it. Even within IAPT, the 2015 review of the national curriculum for the training of Psychological Wellbeing Practitioners (available online https://www.ucl.ac.uk/pals/research/clinical-educational-and-health-psychology/research-groups/core/ psychological-wellbeing from University College London) acknowledged that the theoretical model that underpins Cognitive Behavioural Therapy was not sufficient to describe everything that Psychological Wellbeing Practitioners in IAPT deliver; models and theory of behaviour change were introduced to the curriculum. Most importantly, this review

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acknowledged that low-intensity psychological interventions are a behaviour change method and the COM-B behaviour change model developed by Professor Susan Mitchie and colleagues emerged as the unifying central model that structures low-intensity psychological practice and can be supplemented by models drawn from CBT—and, by implication—other theoretical approaches—to support specific interventions. Developments of low-intensity interventions in other models: ➢

➢

➢

➢

In the field of adult Primary Care Psychological Interventions, there is ongoing development of Low-Intensity Cognitive Analytic Therapy (LICAT) which shows promise as a low-intensity psychological approach for anxiety disorders. Two of my PWP colleagues left IAPT to complete PhDs, during which they tested the efficacy of compassion-based low-intensity psychological interventions. The work of CYP, EMHP, and MHWPs maybe has that broader remit of ‘wellbeing-focused psychologically informed interventions’ that could draw on several theoretical models to inform the interventions. When my students write essays and reflections about the common factor clinical skills (more about them in Chapter 3 of this book) that facilitate the delivery of the CBT-based interventions they are more likely to cite literature from humanistic counselling than any of the CBT literature.

Observing all of this, and as my understanding has matured, I have come to think of low-intensity psychological interventions as an integrative model. That is, low-intensity practitioners must thoroughly understand the theoretical underpinnings of everything that they offer in their clinical work, but they have got the scope to draw on more than one model and set of techniques to support the patient to achieve their goals. That doesn’t mean that I am advocating a free-for all where practitioners make it up as they go along. Safe practice is always within the scope of your training (which should come from an accredited, regulated training provider) and the boundaries and requirements of the role that you are employed in. Training and new learning should only ever be put into practice supported by supervision from someone who knows what they’re doing and within the commissioning requirements and under the clinical governance of whatever team the practitioner is working in. Whatever theoretical model a low-intensity intervention is based on there are some core principles that apply across the board and I have tried to define these in the numbered list below.

Towards a definition I know, the provisos and reaching towards definitions are a bit exhausting, but in low-intensity psychological interventions, we’re doing something new that keeps changing shape, and more keeps being asked of it, so in 2022, this approach has not achieved a final form; we are at a point of exploration with safety equipment strapped on. There are some features that appear wherever low-intensity psychological interventions are practised that could be used as the basis for a definition of this approach: (1) This approach is less burdensome for the patient to engage with than longer-established therapeutic modalities; it asks less of them in terms of emotional labour, time, money, and commitment. (2) Short duration: Low-intensity psychological interventions are time-limited and this is transparent from the outset. (3) Time-limited contact with the psychological practitioner, you don’t just get a short course of treatment, but appointments tend to be shorter than the traditional ‘therapeutic hour’. (4) Interventions are focused on resolving one clearly defined problem. It is, at heart, a problem-solving approach. (5) Use of supporting written, video, or audio educational material and/or worksheets and apps to consolidate learning and guide, the work the patient does in-between contacts with the practitioner. (6) A low-intensity practitioners’ goal for treatment is always to transfer knowledge and skill and power from the practitioner to the patient, building patient self-efficacy with the consequence that there is less need for support from a practitioner in the future. (7) Low-intensity practitioners are collaborative: we practice what we do ‘with’ our patients, not ‘on’, ‘at’, or ‘to’ them. (8) Based on a holistic understanding of the patient and their context, and geared towards enabling the patient to achieve a goal that matters to them, treatment is not ‘diagnosis’-driven and the patient decides what ‘feeling better’ means (shout-out to the Recovery model!). (9) Delivered within integrated systems so that the patient is supported to access the right level and type of care with meaningful choice in what is on offer. (10) Low-intensity psychological practitioners can’t just read a pop psychology book and then regurgitate those ideas to their patients; they are required to work with interventions that are supported by research evidence of a high standard. In England, this means working to implement the recommendations made in the NICE guidelines.

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In CBT-based low-intensity interventions, specifically: (a) Low-intensity practitioners are more likely to deliver a behaviour-based intervention than a cognitive intervention. (b) Cognitive interventions can be offered to relieve emotional distress and reduce barriers to behaviour change.

The power of an acronym Much of the literature about low-intensity psychological interventions carefully avoids using words like ‘therapists’ and ‘therapies’ to describe who we are and what we do. A couple of years ago I resented that, it felt dismissive and belittling. I said earlier in this chapter that I went through a phase of resenting our Psychological Wellbeing Practitioner job title and insisted on using Low-Intensity Therapist (abbreviated to LIT) in my writing and teaching. The Oxford English Dictionary (the dictionary that I’ve got on hand) defines ‘therapeutics’, ‘therapy’, and ‘therapist’ using words that amount to ‘something or someone that provides restorative, curative treatment for ill health’. You could argue that this is what low-intensity psychological practitioners do, but the word ‘therapist’ has got a specific history and meaning in the world of talking treatments that it would be wrong for us to ignore, or co-opt. Further thought led me to accept that ‘practitioner’ (dictionary definition: ‘Professional worker, especially in medicine’) is probably the best and most appropriate descriptor of our function in the provision of psychological care. I much prefer the LIT acronym to the abbreviation of low-intensity practitioner, LIP, but they’re both better than PWP so I can bear it. Maybe the PPN are right and I should accept that we will all be wellbeing practitioners in the near future. Having to work with WP as our acronym fills me with cold dread, so I’ll hold out a little longer. I hear from CYP and EMHP teachers and practitioners that they believe that ‘low-intensity interventions’ and ‘lowintensity practitioners’ are more accurate and useful than descriptions and job titles that use the very generic word ‘wellbeing’. Whichever profession and dimension of low-intensity practice we are in, we all seem to agree on one thing: that ‘low-intensity’ psychological interventions, whichever theoretical model they are based on, doesn’t feel in the least bit ‘low intensity’ to deliver, and there are concerns that the use of those words might give the impression that our work is less important or effective than ‘high-intensity’ psychological interventions based on the same therapeutic models (Fig. 11.1).

FIG. 11.1  Perceptions of the role as being weighted towards industry over care. (Credit: Image by Natalie Hanley.)

Prediction and experience Reports on the experience of Graduate Mental Health Workers captured the risk of a number of ‘dilemmas’ that were predicted to carry across to the new IAPT low-intensity workforce. Text in bold is paraphrased from Shepherd and Rosairo (2008). Inadequate role definition and uncertain professional status, and training that may not equip practitioners to fill a professional mental health role.

Training for a traditional professional healthcare role (nursing, occupational therapy, physiotherapy, etc.) is typically 3  years long in England. This allows scope for supervised practice in different settings as well as teaching on wider

­ rofessional issues like ethical practice and the use of supervip sion. This is alongside teaching on the evidence, knowledge, and skills that combine to form the recognised body of learning that is encompassed by the professional title. IAPT tends to rely on the fact that a requirement for its roles is preexisting knowledge of common mental health disorders and significant work experience in mental healthcare settings. Most of our low-intensity applicants have already got 3  year undergraduate degrees or Master’s level qualifications and the training is a ‘top up’ on this preexisting learning and experience. It was only in 2021 that registration with the British Psychological Society and the British Association of Cognitive Continued

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and Behavioural Psychotherapies became available to low-­ intensity therapists, bringing a formal requirement to work under a specific code of conduct and ethics. A mismatch between what is expected of low intensity practitioners and what they are trained and supervised to provide safely. This paper talks about the risk of ‘hidden complexity’ in presentations that are initially identified as ‘common mental health disorders’.

Less than 2 years ago, I spoke to a GP who believed that the IAPT Long-Term Condition expansion in Primary Care meant that IAPT would provide a ‘Pain management team’ in her practice, the chapter on LTC developments will show how inaccurate that perception was. Primary care is still overwhelmed by the demand for mental healthcare services, and since IAPT is on hand, GPs will often use us as a screening service for access to mental health services, regardless of if this falls within our competencies (Martin et al., 2021). Putting Low Intensity Practitioners on the ‘front line’ as a first point of contact with the service meant that Low Intensity Practitioners might offer an inappropriate level of care and attempt to provide treatment to patients with severe or complex difficulties, or a risk of suicide.

A growing number of services now require patients to undertake a ‘trial’ of low-intensity interventions before they can access an assessment with a CBT therapist or counsellor. This is described as ‘stepped care’ and it has created real problems. Unfortunately on p. 54 of The IAPT Manual in 2021, a table describes that in ‘worse performing services’ patients have been stepped up without a trial at step 2. Services are caught

between following guidelines or trusting the assessment skills and supervision process of their low-intensity practitioners, and they will usually follow the commissioning guidelines. This creates some of the pressures that we explore further in Chapter 8 on practitioner burnout. Referrers might put pressure on Low Intensity Practitioners to work with people who they are not trained and equipped to support.

This does happen and is often a consequence of the lack of other mental health service provision. Overwhelmed GPs and other primary care staff can feel that there is nowhere else for their patients to get help with mental health difficulties. Low Intensity roles are ‘unfamiliar, varied and multifarious, depending on the local context (e.g. client demographics, pressures from referrers, political situation, configuration of supplementary services). Roles vary considerably across regions and even between workers in the same service’.

This is still true, and the differences in what interventions are offered between one practitioner and another, or one service and another, creates confusion about the boundaries and limitations of the role. In general, I think people who claim to practice the same psychological approach should offer roughly the same treatment interventions. However, if you remember the principles of Barefoot therapy, there is a strength in being able to adapt to the needs of local populations. Currently, we tend to ignore that this variation is happening and it might be helpful to think about how we can find a balance between local demands and role definition.

Professional status It is time to talk about our professional status now. You’ll have realised that I like to define the terms that I use, so let’s agree on the meaning of a few more terms that will help us to have a shared understanding for the rest of this book: ● ● ●

What is a profession? What makes somebody a professional? Why does that matter?

Right, the easy one first. What is a profession? My reliable old dictionary contains three words related to this question: ‘Profession’, ‘Professional’, and ‘professionalism’. Without repeating the definitions word for word, these three items give this sense of a profession: that it relates to a paid occupation which requires ‘advanced learning’ to undertake; that the activity related to this profession is specific to that profession alone. So, a professional is someone who has undertaken the advanced learning related to this occupation who engages in the occupation and behaves with the ‘typical qualities or features’ of a professional. An anecdote: a few years ago I attended a speed dating event with another PWP from work, during one of the conversations that evening I spoke to a person who asked about work first, and after a couple of sentences of my answer interrupted with ‘so you’re a professional then?’ Something in my demeanour and the tasks associated with my occupation had communicated the ‘typical qualities and features’ of a professional to him. I have never met a low-intensity practitioner who doesn’t communicate those qualities and features; we are all assumed to hold professional status by the people who we encounter in our lives outside of work.

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Why am I banging on about integrity? We attract a high proportion of people in their early 20s, at the start of their working lives, into low-intensity psychological interventions training roles. As a training provider, I have found that it is my job not just to teach the theory and clinical skills necessary to deliver low-intensity psychological interventions but to model and emphasise the criteria of integrity, ethics, and altruism that define the personal qualities that are assumed of people who achieve ‘professional’ status. It requires courage to engage in training, supervision, and clinical practice with the transparency and honesty that are essential in this type of work. A fear of negative evaluation by

others is human and normal, but it can lead to concealment and dishonesty that have got no place in our working lives. Our trainee practitioners must confront and learn to manage their own anxiety at the same time as acquiring the didactic knowledge and practical skill that will enable them to offer effective care. Standards are high in our training programmes. We understand that if someone passes the assessments that we set then they will become a healthcare practitioner in a position of trust and power in relation to some extremely vulnerable people. The requirements that we set are academic, practical, and personal, and all are nonnegotiable.

The Australian Council of Professions offers this definition of a Profession on their website, which emphasises the standards of morality, integrity, ethics, and altruism that the words ‘profession’ and ‘professional’ convey: A Profession is a disciplined group of individuals who adhere to ethical standards and who hold themselves out as, and are accepted by the public as possessing special knowledge and skills in a widely recognised body of learning derived from research, education and training at a high level, and who are prepared to apply this knowledge and exercise these skills in the interest of others. It is inherent in the definition of a Profession that a code of ethics governs the activities of each Profession. Such codes require behaviour and practice beyond the personal moral obligations of an individual. They define and demand high standards of behaviour in respect to the services provided to the public and in dealing with professional colleagues. Often these codes are enforced by the Profession and are acknowledged and accepted by the community. https://www.professions.org.au/what-is-a-professional/

Core professions Within the English healthcare system the term ‘core professions’ is used to describe professions with a certain standard of qualification (usually degree-level training is a requirement) and professional registration and accreditation with a governing body. Core professions are also regulated; in psychology, that regulation is typically through the Health and Care Professions Council (HCPC) although individual registers, like some counselling registers and the registers for low-intensity psychological practitioners, can be accredited by the Professional Standards Association. Holding a core profession usually requires a practitioner to be a member and registered with a professional body who set standards for the conduct and ethics of their members and regulate adherence to those standards, and who provide accreditation of professional practice that guarantees that a practitioner engages with continued professional learning and development after qualification. A core profession is often a requirement for applicants to higher paid job and professional development opportunities in the NHS, being viewed as proof of core transferable skills as well as specialised knowledge and relevant experience.

Progression In many NHS Trusts (a Trust is an organisational unit that provides care services in a geographic area, or for a specific function), a core profession is a mandatory requirement for access to management and leadership roles. In the world of IAPT, the core professions that are most represented are the Psychology specialisms, General or Mental Health Nursing, Physiotherapy, Occupational Therapy, and accredited Counsellors and Psychotherapists. Low-intensity practitioners are not on the core professions list, which means that our career development can feel truncated, and we are often managed by people who do not have any insight into our therapeutic approach, or experience of the realities of our working conditions.

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I was lucky to work in a team that recognised the value of its low-intensity practitioners and allowed those of us with the Certificate in Low-Intensity Psychological Interventions to apply for jobs in leadership and management at the higher pay bands. This allowed PWPs to progress to clinical leadership and senior management roles, some going into leadership jobs in the national IAPT programme and other healthcare settings. The work of those pioneering leaders emphasises the core transferable skill set that low-intensity practice develops in people: organisation and time management, problem solving, resilience, brilliant communication, the ability to connect meaningfully with people from diverse

backgrounds and life experience, and build effective working alliances. Other teams have not enabled low-intensity practitioners to apply for leadership roles (unless they had a core profession before low-intensity training) and the career progression, and pay grade of their low-intensity practitioners is capped. Even in a team that did more than most to support the career development of low-intensity practitioners, as a Lead PWP with oversight and responsibility for the clinical governance of the work produced by a team of PWPs in a rapid and significant service development my pay was equivalent to a newly qualified CBT therapist.

Progression into management isn’t the only route that is attractive to low-intensity practitioners (Fig. 11.2). Our clinical work consolidates our core therapeutic skills—those related to interpersonal competence that transfer between the therapeutic approaches. Many people are attracted to the low-intensity role because they want to deliver psychological therapy; low-intensity training is often the most accessible and affordable option available. There are low-intensity practitioners who aspire to train in evidence-based counselling approaches like interpersonal therapy (IPT) who are barred from funded training in the NHS because the pay band at which qualified low-intensity practitioners deliver care is below the threshold for the training programme. The pay band is assumed to indicate the competence of the practitioner and the quality of their education and experience. Given the tremendous innate potential and accumulated skills represented in the low-intensity workforce, the uncertainty of our professional status, the difficulty in accessing progression opportunities, and significant disparities in financial compensation compared to the rest of our teams will inevitably lead to high turnover of staff.

Knowledge, skills, and attitudes Practitioners who leave low-intensity practice are most likely to go to CBT training. To become an accredited CBT therapist, you must complete an accredited training course and hold one of the core professions listed below. Medicine (psychiatry or GP)

Nursing (mental health)

Art therapist

Accredited counsellor or psychotherapist

Social worker

Occupational therapist

Psychologist (counselling, clinical, health, education, and forensic) To access an accredited training programme linked to an IAPT ‘high-intensity’ training vacancy, the applicant must provide

proof of a core profession or something equivalent before the applicant can begin training. The British Association of Cognitive and Behavioural Psychotherapists (The BABCP) offers a ‘Knowledge, Skills, and Attitudes’ route; applicants without a core profession can complete a portfolio of evidence to show that they have acquired equivalent knowledge and experience through their working life and education. The volume of lowintensity practitioners who successfully progress through this route leaves little doubt about the professionalism of this workforce. A recent concession was made that allows for a reduced KSA portfolio when the applicant has completed a British Psychological Society (BPS)-accredited degree in Psychology and a BPS-accredited low-intensity interventions training programme.

Direction of growth Achieving recognition of our professional status is an ongoing task and is complicated by how our approach came into being. Most healthcare professions had a slow development as the need for them became apparent, a community of practice formed, and the boundaries of their field were defined from the inside, followed by organisation into regulating bodies and formal professional recognition that allowed practitioners to claim that they have a ‘core profession’. Low-intensity interventions are being defined in an almost opposite direction. There was that initial slow growth as the pieces of the approach came together, as I describe in Chapter 1 of this book, and we had the emergence of Primary Care Mental Health Practitioners and Graduate Mental Health Workers, but then outside forces swept in and prompted a rapid development of this approach along lines that were presumed rather than discovered. The hot-house growth and development of the approach was very much imposed from the outside.



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FIG. 11.2  The crossroads of a low-intensity career path. (Credit: By Natalie Hanley.)

Imposition In England, amongst the rapid changes in the last 15 years (I am writing in 2022, for context), we have seen service developments that grew organically in response to the needs of local populations, led by practitioners, swept aside in favour of an ideologically led framework governed by academics, that draws on a narrow range of theory whilst presuming that universal implementation will be to everyone’s benefit. The fractures that this caused were as inevitable as they were predicted. One of the dynamics that contribute to the harms within the system is the interprofessional communications and relationships that are the topic of this chapter. You can’t work together to deliver a service without noticing things about each other; that’s true for interpersonal relationships but also true for interprofessional relationships. IAPT teams were imposed rapidly on areas that had previously had, usually, some provision of primary care psychological services. Those preexisting services were usually made up of counsellors, Primary Care Mental Health Workers, Graduate Mental Health Workers, and practitioners with Social Work or Mental Health Nursing qualifications. The implementation of IAPT often meant the integration of those preexisting teams with a surge of new people, including new managers, new peers, and what must have felt like a tsunami of CBT and lowintensity trainees. Comparisons were inevitable.

Tribes The exchanges of opinion about IAPT can become heated. For some of the practitioners in the longer-lasting therapeutic traditions, the rise of CBT and the implementation of stepped care systems appear to present some sort of existential threat. On the other hand, we have IAPT’s proponents who praise ‘evidence-based practice’ with almost religious fervour (I can say that, I’m religious), essentially saying that if a theoretical model and technique or method hasn’t been tested in multiple randomised controlled trials then it shouldn’t be implemented in practice. This is at the expense of the accumulated experience of a century of therapeutic practice that predates modern empiricism and disadvantages those approaches that weren’t developed with the scientific method ‘baked in’ to the approach. The most avid IAPT supporters are often the same as those people who practice and highly value Cognitive Behavioural Therapy, and as a group, they can sometimes appear scornful or dismissive of humanistic or psychodynamic approaches, wary of the quasi supernatural tone that some counsellors and psychoanalytical practitioners can use when they talk about their work. Amongst some (but certainly not all) Cognitive Behavioural Therapists and Psychotherapists, there is a suspicion of a reliance on the ‘felt’ elements of therapeutic work; the interpersonal and emotional dimensions that are present but less central in Cognitive and Behavioural work. More seriously, there are also expressed concerns about the accountability of some counsellors and psychotherapists. The IAPT programme has some problems with governance on a national level, but there are built-in checks and balances that ensure that anyone practicing within the programme meets a standard of training, supervision, and accountability that can be absent from other settings.

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The rabidly compliant unquestioning IAPT adherents (amongst which group I would have counted myself for many years) tend to fuel the exploitation of low-intensity therapists and threaten the future of the profession by creating conditions that lead to practitioner burnout and problems with staff retention that are not sustainable in the long term. Frankly, if we don’t change the conditions of work and professional recognition of low-intensity practitioners and start keeping more of them in the job, then I don’t see how IAPT will be sustainable for much longer. There’s more to say about retention, and I’ll bring it up again in Chapters 7 and 8 where we look at burnout and supervision, respectively.

Different, but equivalent? Subjectively, it can feel like there are deliberate efforts to hold low-intensity psychological practitioners below the status of professionals, as if there is a fear that we might grow too big for our boots, as if our independence would be a threat. This causes frustration when we compare our contribution to our teams with the roles of the other professions. One of the most contentious issues when I joined IAPT in 2010 (and still, if we’re being honest) was the matter of disparity of pay between the professions. Just as we were all aware that we brought something very different to the team, we were all sure that what we provided was essential to the team’s success. As low-intensity practitioners, our conditions of work weren’t necessarily bad, but they felt bad in comparison to the conditions, rewards, and recognition received by other professional groups in the team. I acknowledge that our training is not equivalent to that completed by the CBT therapists and counsellors; our clinical interventions are not so complex. In a typical service design that is balanced by the level of responsibility that low-intensity practitioners bear. Even when the difficulties that people present to the service are complex and severe, the low-intensity practitioners still hold the highest volume of the work that the team completes. We provide the initial assessments of clinical risk and plan the course of care. Most qualified low-intensity practitioners train as supervisors, support research initiatives, and service evaluation, and are the face of the service to other local organisations and patient populations. In IAPT teams and most other settings where low-intensity interventions are implemented in England, the low-intensity practitioners work alongside colleagues who have professional status and the substantial traditions and protections that come with that. Many of the PWPs who progress to CBT training and qualification say without hesitation that the lowintensity practitioner role is harder—more demanding and exhausting—than the high-intensity CBT role. We all know the value of the counselling approaches that, when done well, can produce almost miraculous changes. In light of this, it is difficult not to resent the pay disparities in the teams, and they do not reflect the value added to the service delivery by different professional groups. Low-intensity practitioners and low-intensity psychological interventions are different to the other psychological professions and counsellors; I don’t intend to argue that our 1 year of graduate or postgraduate training is equivalent to the 2 years of postgraduate level study required to qualify as a cognitive behavioural psychotherapist, or the 3 years of doctoral level study that is required to qualify as any kind of psychologist. I do argue that nonequivalence is not the same as ‘of less value’. What low-intensity interventions lack in range of clinical interventions, we make up for in the rapid accumulation of expertise in core skills and the weight of responsibility that it falls to us to manage.

Never alone One of the strengths that low-intensity practitioners tend to acquire quickly is the ability to accurately assess the main presenting problem of the person they are talking to. When the presenting problem is either uni-polar depression or an anxiety disorder the level of care the person is offered should be determined by the nature of any anxiety disorder that is identified (Social Anxiety Disorder and PTSD are not currently treated with Low-Intensity Interventions) and the severity, longevity, and complexity of the problem. Realistically, there are a vast number of people for whom low-intensity interventions are not a sufficient level of care which requires there to be several treatment options available after assessment. Low-intensity psychological interventions shouldn’t be offered in a vacuum. Both professional bodies who offer registration for low-intensity practitioners stipulate that people on their registers are only supported to work within ‘stepped care’ systems. Indeed, most low-intensity practitioners will have started a piece of work with a patient that seemed helpful in the first appointment or two, only to find themselves badly out of their depth when new information or complexities came to light later in treatment. What we offer can be done safely and well with a lot of people but as a low-intensity practitioner you never want to find yourself isolated from the rest of the system. The championship of ‘evidence-based’ organisation of psychological therapy services sometimes overlooks the weaknesses in the research evidence base that they use to justify their expectations. They don’t acknowledge the biases that



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inform the research questions that are asked, or the personal and political agendas that control the distribution of financial investment in research projects. Every PWP has met countless people who access IAPT and whose needs cannot be met with the NICE recommended low-intensity interventions. We sometimes find ourselves working with a person whose problem fits the descriptors for a mild-moderate common mental health problem—exactly who we should be able to help—but our small toolbox of techniques doesn’t help at all. What is going on there? Is the toolbox too small? Are our critics correct that what we can offer is superficial and ineffective? No, the problem is often that we work in a system that paralyses learning. For most lowintensity practitioners, there is no time in the working week to reflect and share learning with our colleagues. The rate at which new research evidence can be implemented in practice is also hindered by snails-pace of the NICE review process and the fact that there is no adequate communication between IAPT teams that would allow us to disseminate best practice and steer away from practices that do harm to staff and patients. Low-intensity therapies are not the whole earth; they are just one part of the psychological healthcare ecology.

Evidence-based costs Very straightforward principles and ideals are described in the literature about IAPT that don’t necessarily reflect the emotionally charged melting pot of traditions, experience, values, and priorities that can come together in an IAPT team. The transition from the old ad hoc, unquestionably inadequate, provision of psychological care in primary care to the desperately needed national programme has been a bewildering and personally painful experience for many individuals.

Counselling in IAPT The route to being a counsellor has never been particularly cheap or easy. Most training has to be self-funded. Would-be counsellors have to find thousands of pounds in money to pay tuition fees and to pay their supervisor. They also have to provide hundreds of hours of voluntary sessions to meet the requirements of their courses. As a profession, it tends to attract a majority of white and middle class women. In my local area, there had been a team of primary care counsellors alongside the Graduate Mental Health Workers and Primary Care Mental Health workers who had delivered low-intensity mental healthcare in the GP practices and were later absorbed into IAPT. Most of the counsellors had worked in the small local area for more than a decade. They were dedicated to delivering care for the population of that area, which had significant socio-economic challenges and great racial and cultural diversity. Some counsellors and psychotherapists, in my experience, approach low-intensity practitioners with a wary and puzzled suspicion. To this group, the low-intensity practitioner is the embodiment of changes that threaten the existence of the professions and practice that they value. We are a visible reminder of how they have been sidelined and dismissed. I often think that the psychodynamic and humanistic counselling practitioners with two to three decades of experience must feel that the IAPT programme thrust them into a childcare role. They worked independently and competently for years and then suddenly their ‘patch’ was infused by what must have felt like a swarm of toddlers. We were early career practitioners who ran around using words like ‘therapy’ and ‘recovery’ about our work, exhibiting an undue confidence in our miniscule, hastily patched together model and method. I wouldn’t blame counsellors if the thought of IAPT and PWPs disappearing back to whence they came didn’t cost them any sleep. The world would go back to business as usual, without IAPT and its messy and inconvenient nursery of wannabe therapists. I have been incredibly lucky to work alongside counsellors who not only expressed respect and appreciation for my work but who offered friendship, partnership, and support in exceptionally demanding working circumstances. Being in the same building as another member of my team was rare, and always treasured. The most rewarding days that I have spent in IAPT were those when my clinic day offering low-intensity interventions in a room at a GP practice happened to overlap with a counsellor being in the same venue at the same time. Whenever possible we would have lunch together, and our conversations were more effective 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 when I thought that counselling might be the right option for the patient, and spoke at length about our ways of working. Those conversations with counsellors 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 filled the week just from observing them, and learned to appreciate the difference between what could be held in counselling, and what the other processions in the team were able to provide.

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An example of the benefit of input from the counsellors was an angry young person who came to see me for an assessment appointment with high scores on the PHQ-9 and GAD-7 indicating severe depression and generalised anxiety. They had experienced bereavement and other chronic adverse circumstances, and were clearly struggling, not knowing how to cope with their feelings. I felt that we ought to be able to offer something, but the IAPT service was not commissioned to provide anger management. I was, reluctantly, prepared to discharge the patient from IAPT with the phone number of the local anger management course until I spoke to the counsellor. Without sharing any personal details, I gave a counsellor my impression of the presentation, and my worry that they would end up not getting any help. She immediately saw that the anger could be an expression of grief and accepted the patient onto her waiting list. They completed a course of counselling together and the patient moved to recovery.

The dawn of a new age The ‘evidenced-based’ lobby has a stranglehold on planning and commissioning so it was perhaps inevitable that counsellors would receive the brunt of the IAPT programmes’ attention eventually. The problem, you see, is that the word ‘counsellors’ can be used to describe all sorts of training of different qualities and value. One ‘counsellor’ might have a Master’s degree in the subject, be accredited with a reputable professional body and practice under weekly supervision. Another might hold a level 4 certificate (the equivalent of the first year of a degree programme), be registered but not accredited with a professional organisation, and have supervision only occasionally. One friend described counselling training and regulation as ‘the wild west’, which is at odds with the guarantee of measurable and consistent quality that widespread implementation of psychological therapies in primary care demands. The IAPT programmes’ response to this came a few years ago with a push to make sure that all of the therapists who were employed in IAPT as counsellors were offering the same evidence-based approach. No matter their previous experience, qualification, and therapeutic modality, the counsellors in our team were all asked to undertake a specific training in a person-centred approach that met IAPT training and qualification standards. All of those counsellors who had worked in our area for decades were students again. Some valued the training; it was congruent with their approach and they could see the benefit for patients. Others were unable to make the leap from other approaches that they had practised for years, and resigned. Those supportive and companionable lunches were over, and our patients lost access to some highly skilled therapists.

Tension in the team Although most counsellors will train to work with both depression and anxiety, the IAPT outcome data (more on that in Chapters 2 and 10) quickly showed that counselling for anxiety rarely made much difference to the self-reported symptoms of generalised anxiety. In fact there was some risk that a counselling treatment for anxiety would make symptoms worse. After our local University number-crunched our dataset and presented the results at a team away day, PWPs were told not to refer anyone to the counselling waiting list who needed treatment for anxiety; we were only allowed to ‘step’ people to counselling for work on depression. In 2003, the recommended psychological interventions for depression included counselling, CBT, and guided self-help. On further reviews of the guidelines, this has changed. The 2021 NICE pathway for depression, which was replaced in 2022 with updated guidelines for recognition and management of Depresison in Adults (NICE, 2022), recommended that low-intensity interventions should be a first point of care for depression. If this is not successful then CBT, Interpersonal Therapy (IPT), Behavioural Activation, or Behavioural couples therapy for depression were the next step. Only if these are declined should we consider counselling of up to 6 to 10 sessions over 8 to 12 weeks or short-term psychodynamic psychotherapy up to 16 to 20 sessions over 4 to 6 months. NICE added this note: ‘Discuss with the person the uncertainty of the effectiveness of counselling and psychodynamic psychotherapy in treating depression’. That guidance is no longer available and instead the 2022 guidance places an emphasis on patient choice of treatment intervention, but also places interpersonal psychotherapy and counselling respectively as the 8th and 10th choices of intervention for less severe depression. This created some unfortunate dynamics. The gold standard of research evidence is the randomised controlled trial; therapies that could prove that they were effective through research that was designed with this specific quantitative methodology (usually this is CBT and CBT informed low-intensity interventions) were valued more highly by NICE than treatments that most—but by no means all—patients asked for (counselling). However, the lack of evidence does not mean that an intervention is not effective. CBT has had an ethos of empiricism since it’s very early days. CBT therapists are

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e­ ncouraged to adopt the role of ‘scientist practitioner’ and to support their patients to adopt an empirical, enquiring attitude towards their problems and experience. CBT and CBT-based low-intensity interventions use the language of experiments and testing, and this includes frequent use of ‘outcome measures’; questionnaires that are used to quantify the patient’s perception and experience of their symptoms. CBT as an approach has a comfortable fit with the research methodology that NICE prefers. Counselling and psychodynamic therapies are not based on testing ideas through supported behaviour change but on a relationship dynamic. That isn’t to say that CBT therapists aren’t in a relationship with their patients, or that counsellors and psychotherapists don’t use specific theoretical models and clinical techniques to support change, but the change method—what is expected to make a difference to the client or patients’ unwanted symptoms or experience—is different in each approach. What counselling draws on is more difficult to measure than the models and techniques that are at the heart of CBT based interventions. Counsellors are now playing catch-up to produce an equivalent evidence base for the efficacy of what they offer. In IAPT teams, this can create an unhelpful competitive and defensive atmosphere where everyone feels that they have to prove that their therapeutic model and clinical method has worth and value. The changing NICE guidelines between 2003 and 2021 also imposed changing limitations on what practitioners in each role are allowed to offer and what problems they are allowed to work with. These limitations do not always fit with the practitioner’s understanding of their own competencies. For example, many counsellors feel that their core training equips them to work with both depression and anxiety disorders but IAPT services commission counsellors to work only with depression. ‘Counselling’ is a job description that covers a wide variety of therapeutic modalities and levels of qualification. Each counsellor practices quite differently from others. So the counselling staff group can find the boundaries of IAPT commissioning and the requirements of practising in IAPT restrictive and frustrating.

In-house At a training event in 2019, an IAPT service had presentations about all of the modalities that we offered in the team. There was a sense in the room that many counsellors felt undervalued 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 focused on specific protocols for specific disorders. You could see where some of the disagreements might come in, and questions from the counsellors for the CBT speakers were both pointed

and ­anxious. How did patients feel to be subjected to these models and methods? Where was the room for the person in what was being described? The CBT Lead stood up and eloquently acknowledged the value of the therapeutic alliance in CBT, showing that even though the protocols described specific models and techniques, none of it would be effective without the interpersonal and engagement skills that the counsellors feared were absent from the CBT way of working. The CBT therapists took the presence of those skills for granted in their work and understood that there were common competencies that were used across all of the professions so had reserved their time to talk about the elements of their approach that were less familiar to all of the practitioners in the room. That seemed to help.

Trainee practitioner recruitment We’ve superficially touched on the dynamics between the professions in IAPT teams; before we close this chapter we’ll talk about some of the tension created by recruitment practices and the differences within the low-intensity workforce. You might remember the Graduate Mental Health Worker roles that were the predecessor of the current low-intensity roles from Chapter 1. The Graduate Mental Health Worker role was developed to make use of the psychology graduates in England who were an underutilised resource. The graduates would get practical training in the application of the theories that they had studied, and access to clinical practice opportunities; primary care would get some much needed boots on the ground. The Psychological Wellbeing Practitioner in IAPT was imagined to be different to the graduate mental health worker. A degree in any subject was not required, although there have always been postgraduate training routes. The role was designed to appeal to support workers and people with substantial life experience but no professional background. This is sensible; a psychology degree is not a particularly helpful preparation for life as a low-intensity practitioner.

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Saturation In low-intensity practitioner recruitment, we get hundreds of applications by people with increasingly high levels of academic qualification flooding into every training vacancy. Recruitment was one of the responsibilities that were available to Senior and Lead PWPs in my old team; so I was able to participate in the process several times in the endless rounds of recruitment that IAPT services are caught in. There was one particularly memorable year when we received over 400 applications for eight training posts. It took us days to read the applications and shortlist for interview, and we became increasingly frustrated by the personal statements that had clearly been copy and pasted from other job applications in which the applicants spoke about applying for ‘this Assistant Psychologist post’ (NB, a PWP is not an assistant psychologist) to further their aspiration to be a Clinical Psychologist. The statements in which the applicant said anything about wanting to do the role that they were ap-

plying for were rare, and treasured. NHS hiring procedures are tightly monitored and points-based, we weren’t allowed to let preferences or instinct inform our selection, and we had to reject people from the shortlist who couldn’t tick the same boxes of academic achievement and work experience as the people who had planned their application as part of their map towards clinical psychology, complete with coaching from previously successful candidates. We ran three interview panels, each with three senior staff on the panel, in parallel for 2  days. Many of the applicants had completed MSc’s or PhDs in related subjects. They were articulate, they spoke about how excited they were to practise low-intensity interventions, they were able to demonstrate the fundamentals of good interpersonal skills in a role play. We sent out job offers to the successful candidates and resisted the temptation to start a pool to bet on how long each would last. We were crying out for people who would come into the team and find the work rewarding enough to stay, for a few years at least.

The HEE announcement There was some drama in the summer of 2021 when Health Education England, the body that commissions IAPT training courses, announced that if you took a place on one paid psychological professions training course, then you would not be eligible to receive funding for further training programmes until you had been qualified for at least 2 years. This might sound reasonable, after all HEE invests thousands of pounds in every single training place. When you consider that we’ve got more than 30 courses delivering one or two training cohorts per year with cohort sizes varying between 20 (ish) and 100 (ish) students, the cost soon adds up. If every accredited low-intensity training programme ran one course per year with only 20 students, the cost to HEE would exceed two and a half million pounds, and that’s just for training. If you add the typical training salary to that then the minimum possible annual cost to the public purse for IAPT low-intensity trainees is closer to 18 million. Salaries come from the local service and the clinical commissioning groups budgets. Those are ridiculously low numbers by the way; a cohort of 20 wouldn’t get most universities out of bed in the morning. Of course those training places aren’t funded for the fun of it. They are funded because there was a gap in the provision of care for the population of this country that we are trying, rather desperately, to fill. We need those practitioners in practice; we need them to help people who have got depression and anxiety. Chapter 7 of this book examines some of the reasons why it might not be possible for some practitioners to stay in the role, even when it is the job that they want to do. Unfortunately, it turns out to be many of the people who have taken up those training places over the years aren’t interested in the unglamorous drudge of primary care psychological therapies (Fig. 11.3). They are early career aspiring psychologists who want to take the qualification and everything else that the low-intensity experience can give them and get out of there to their true calling—which turns out to be CBT practice, or clinical psychology (which both come with

FIG. 11.3  There can be subjective perceptions of the psychological professions that inform career aspirations, with low-intensity interventions still striving to take their place. (Credit: By Natalie Hanley.)

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another 1–3 years of publicly funded training, a significantly higher training salary, and a more prestigious job title when you’ve finished)—as quickly as possible. A substantial number of people who had secured and benefitted from the training and clinical practice experience that low-intensity practitioner roles provide stated baldly that if they had known that they would have to stay in the job after training, they wouldn’t have bothered to apply for the training. So, when Health Education England told the current and recent low-intensity students that their aspirations would have to be delayed for 2 years there was an outcry. A petition was got up; 2000 people signed it in less than 24 h, eventually more than 6000 people signed. Health Education England delayed the implementation of the new rule to April 2022. If I sound bitter, well, I’m not. I was hurt when the outpouring of outrage demonstrated how many of my colleagues, students, and supervisees had lied to me over the years. It offended my values that so many people would enter a professional role, or even a quasiprofessional role, under false pretexts. To get through the interview process, our trainees convince their teachers and their IAPT teams that they want to be a low-intensity practitioner, and that they are interested in delivering low-intensity psychological interventions. Several of us ‘old hands’ were also taken aback and slightly bewildered by the wording of the petition which spoke about people being ‘forced’ into low-intensity training and practice. The role of low-intensity practitioner is a high aspiration for thousands of people. I remember when I first saw a job advert for an IAPT low-intensity training role in 2008. I felt the flutter in my stomach that you feel when you know you’ve found the right fit. At that time, I didn’t even have my BA degree. I was 25, married, and pregnant, working as a support worker in a low-intensity team in the NHS. I couldn’t believe that I would ever be in the position to do the work of an NHS psychological practitioner. That flutter in my stomach though… I knew that was the job for me.

Petition …many people have completed or are about to complete an HEE-funded course under the impression of it increasing their chances for the Doctorate. This is something many course providers have recommended both on the Clearing House and live events. Therefore, many have attended these courses on the grounds that it will aid their application for the doctorate. Many people were forced due to the competitiveness of other roles such as Assistant Psychologist. Others have also felt forced into roles such as PWP or HICBT due to their own financial situations. …For many people, this literally affects their reproductive rights. Many of them may have intended to begin their journeys to having children (Including IVF and fertility treatment) which they would have put on hold due to applying for this post and knowing the 3-year commitment. For many people who are above a certain age bracket, this will write the profession off for them as they will be gambling between having children or a profession, which is discriminatory.

From ‘Delay the implementation of the 2-year HEE funded requirement for the DCLIN application’ petition on http://change.org.

Status and inclusion Some of the concerns raised are legitimate. There has always been a recommendation that services who host Low-intensity training places should make sure that they are able to offer full-time permanent contracts after the qualification is complete. Many services can’t make that commitment because of failed negotiations with their commissioners. Others exploit the training funding to acquire staff year after year with no intention of retaining them. Trainees in those services are used as fodder to do jobs like mental health triage and, in one rather bizarre example, reception duties that the team can’t otherwise afford. So what is a trainee on a 1 year contract with no job security beyond the year to do? Of course you apply for everything, and hope that something comes through. What came to light after the HEE announcement was forcefully emotive for all of us, and it brought the problems around equity of access to psychological training to light. Any training that confers the title of ‘Dr’ when it is completed will appeal to a lot of people, but Psychology in particular confers a great deal of a certain type of status, influence, and power. It’s obvious that historically the people who get access to that power and status tend to be, on the whole, white, straight, able bodied, and relatively affluent. Some of the flood of applications for every low-intensity training place is an expression of ambition that is frustrated by systematic inequities and bias in clinical psychology. We’ll all be better off if the glorious diversity of our communities is properly represented in the very powerful and influential world of clinical psychology. Part of me welcomes the opportunity to give minoritised and otherwise disadvantaged applicants a route to their goal. There have been a handful of people who I have met at interview who I would gladly let stand on my head to progress their career, but they are a tiny fraction of the people who come to IAPT. Another part of me wants to see high-quality psychological care delivered sustainably in primary care, and wishes that clinical psychology would get its house in order and work its issues out somewhere far away from my doorstep.

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A year on the inside As a counterpoint to the petition a Senior Psychological Wellbeing Practitioner in a large IAPT service, provided me with an account of what a year looked like from the service leadership perspective, and why the problem of retention needed to be resolved. In Sam’s words: March You are an IAPT service. You are awaiting confirmation from the commissioners as to whether you will get the funding to match the NHS long-term plan or not in the new financial year, the decision hasn’t been made yet. You have 10 Qualified PWPs and 3 trainees half way through a 12 month contract, just beginning to find their feet with treatment. As you had no guarantee of future funding, you couldn’t offer them permanent contracts without risking a management of change scenario for everyone you currently employ. Success, you get enough funding to employ 3 more PWPs! However your trainees are only half way through their contract, and this money isn’t there to help you see the people already on your waiting lists more quickly—you are now expected to do more, effective from April, regardless if you’ve had time to recruit or not. You go to ad, and you manage to poach a qualified PWP from another local service, where they’ve been unhappy. Feel a momentary pang of guilt as to the problems that will create in the locality they’ve moved from, then get on with the recalculations. You now have 11 Qualified PWPs, 3 trainees and 2 unfilled qualified posts. August One of your Qualified PWPs leaves because they are no longer happy in the role, there is no further room for development and they feel stuck and frustrated. You now have 3 unfilled posts, but 3 trainees about to qualify, right? All good. Except 1 of them is going straight to Clinical Psychology training and one of them is going elsewhere. And because you try to be a decent service and not use your trainees as qualified members of staff, respecting their learning curve, you were only just getting to the point where the hours of training that have been put in begins to pay off in terms of the amount of patients seen. The 2 who are leaving finish their course, but the effect is felt immediately as they are no longer taking on new cases.

You recruit to 4 new trainee roles, reviewing and interviewing from hundreds of applicants, then offering feedback to those despairing, often tearful because they’ve been trying to get on the course for years and they haven’t been offered an opportunity yet. “What if I took a loan to do a Psychology course?” and the like is heard alarmingly often. Your 4 new trainees are on a 12 month contract because, as before, you have no guarantee you will have enough funding to keep all of them again—they will start seeing a few patients in 3 or 4 months time. You still have 11 qualified PWPs and 2 unfilled posts—you can’t recruit any newly qualifieds from other services, they are all on permanent contracts because funding works differently in those services, and/or they have not stayed in the PWP role post-qualification. November Intake for High Intensity CBT training begins. 3 of your PWPs get on the course. You now have 8 Qualified PWPs, 5 unfilled posts and 4 trainees. If you’d have managed to keep all 3 trainees from the last cohort, you’d have 10 Qualifieds, 3 unfilled posts—you’d have at least managed to stay stable, even if that newer funding hadn’t been used effectively. As the local universities only run a PWP course once a year beginning in October, you have no chance of any newly qualified practitioners looking for jobs to fill the positions of those moving on. You might get a qualified PWP to apply from elsewhere—but they’ve also applied to 2 other services and you have to try and persuade them to come and work for you. You could now theoretically offer all 4 of your trainees permanent contracts, except they won’t actually be in a position to do the work you need them to do for 12 months. And half of them are likely to not stay anyway, whether their contracts are permanent or not. In the meantime you have spent hours and hours on recruitment and training, time and resource that could have been given to your current staff to help them feel valued, help them learn or achieve goals, or simply on their wellbeing, making them want to stay a bit longer. But to do that without impacting patient waiting lists you have to have an appropriately funded service that is also fully staffed… You appeal for help. You’re told you can have more temporary funding to employ extra trainees on a 12 month contract….

‘Oh bother’ Why am I telling you all of this? We knew that we had retention problems; we’ve already spoken about those in this book. There are legitimate reasons why the low-intensity role is unsustainable for a lot of people. When you have to weigh up your job against your health a sensible person will choose their health, or their body will choose it for them, refusing to function until the unbearable demands are relieved. We had always known that many of our low-intensity candidates pursued the job because it was a step towards becoming a clinical psychologist. What the HEE announcement did was expose the extent of this. The use of low-intensity roles as stepping stones is one reason why we still haven’t got robust teams of experienced practitioners after 10 years of trying to build them. People were occupying space in those teams without any intention of accumulating experience and contributing to the aims of the programme or the development of this new profession. They had good reasons for doing so but this was demoralising and destabilising for those people who had aspired and are committed to providing primary care psychological therapies. It impeded the accumulation of expertise and leadership that you must have at the heart of a primary care service. ‘Oh bother’, as Winnie the Poo would say. There aren’t any fast and obvious solutions to the problems with recruitment and retention. I hope that the future will be more balanced. We will always have highly academically capable and accomplished candidates in this work, I very much



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hope; you need the qualities of intelligence and curiosity alongside compassion and commitment to make a great low-­ intensity practitioner, and there’s no doubt that a few years in low-intensity practice will build skills and qualities that transfer well into most settings. Alongside the traditional training routes, we now offer opportunities to train as an apprentice. The apprentice route reduces the academic entry requirement for training, whilst maintaining the same standards of clinical competence. The idea is that people who might not have academic qualifications but who have got extensive, enriching, life experience, and highly developed interpersonal skills can get access to a Level 6 (equivalent to undergraduate) qualification and be paid to train. An apprenticeship provides opportunities for more people who aspire to low-intensity practice to achieve their ambition, and brings some balance in gender, age, and other attributes that our teams need urgently. This is an exciting time; it feels like there is hope for some stability and sustainability in our emerging profession.

Next steps This has been a wide-ranging chapter. I have tried to describe how low-intensity practitioners are situated in relation to the identity of ‘professional’ alongside other psychological approaches. We’ve touched on some of the dynamics that affect the low-intensity workforce from the outside, and within the professions, and acknowledged some of the challenges that have arisen in the first years of widespread implementation of low-intensity interventions. At this moment in time, the lowintensity professions haven’t got a cohesive identity, but registration gives us the first step in that direction. Our task over the next few years will be to find our voice as an independent group, to produce our own research and literature, to demonstrate our equal value alongside the other psychological professions.

References Martin, C., Iqbal, Z., Airey, N., Marks, L., 2021. Improving Access to Psychological Therapies (IAPT) has potential but is not sufficient: how can it better meet the range of primary care mental health needs? Br. J. Clin. Psychol. https://doi.org/10.1111/bjc.12314. June 14. NICE, Depression in adults: treatment and management. [NG222]. https://www.nice.org.uk/guidance/ng222. Shepherd, M., Rosairo, M., 2008. Low intensity workers: lessons learned from supervising primary care mental health workers and dilemmas associated with such roles. Ment. Health Fam. Med. 5 (4), 237–245. Retrieved June 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2777579/.

Further reading Meadows, J., Kellett, S., 2017. Development and evaluation of cognitive analytic guided self-help (CAT-SH) for use in IAPT services. Behav. Cogn. Psychother. 45 (3), 266–284. https://doi.org/10.1017/S1352465816000485. NHS England, 2015. National Curriculum for the Education of Psychological Wellbeing Practitioners, third ed. Author, London. Retrieved from https:// www.ucl.ac.uk/pals/research/cehp/research-groups/core/pwpreview/docs/PWPREVIE_-curriculum.

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Chapter 12

Discussing international applications Elizabeth Ruth and James Spiers University of Bradford, Bradford, United Kingdom

This chapter offers insights into the potential applications of low-intensity psychological therapies in contexts outside of the IAPT programme in England. Whilst neither James nor Liz have experience of working in psychological therapy outside of the United Kingdom, this chapter offers reflections from the experiences of the potential gains and pitfalls based on their experience from working within the role in the English healthcare system of the NHS. This chapter is inspired by a 2-h recorded discussion between Liz and James whilst posing questions as to how they see the potential applicability of low-intensity interventions, internationally. Excerpts from the transcript are merged within the text to hopefully provide the reader with a sense of the live narrative and dialogue, as well as conflicted opinion, and healthy debate.

Aims of this chapter ●

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To consider the real-world translation of training and uptake of the role of a low-intensity psychological therapies practitioner. To offer reflections from the lived experience around the potential gains and challenges of the role and its potential application outside of the English NHS IAPT programme. To consider the real-world applicability to contexts outside of the NHS.

There is a growing recognition that the world is facing a mental health crisis. The COVID-19 pandemic has shone a worldwide light on the wellbeing of populations and the cracks have become visible. Not only have preexisting mental health conditions gained new recognition but the stress and horror of the pandemic, and the measures that were implemented in response to it, have resulted in a sharp increase in the onset of common mental health disorders worldwide. Just as England had to reckon with the prevalence and impact of common mental health disorders in the 1990s, now, so do most nations. Several countries have already implemented stepped care psychological care services in primary care. Japan, Australia, and Canada were amongst the first countries to implement programmes with a similar ethos to IAPT, although with limited or no low-intensity provision (MHCC, 2018; Kobori et al., 2014). The high prevalence and vast care gap for common mental health conditions such as depression and anxiety mean that countries need to diversify and scale up options for care for these conditions if they are to move towards, or reach, universal health coverage. New funding and effort will be needed to add evidence-based psychological care to existing health and mental health services as well as to social care settings, the criminal justice system, schools and universities, and online environments. Delivery of psychological care needs to be expanded in primary healthcare settings and through community providers. Other key strategies for scaling up evidence-based care for common mental health conditions include enabling self-help and making better use of digital technologies. World Mental Health Report: Transforming mental health for all (WHO, 2022)

Although the authors of this book do not unreservedly recommend that the IAPT programme is copied worldwide, we hope that we have shown the range and versatility of low-intensity psychological interventions and their benefits to both physical and mental healthcare systems. A low-intensity psychological practitioner can support computerised and bibliographic interventions, can deliver care on a one to one basis, and can facilitate psychoeducation courses that can be attended by multiple people at a time. They are well-placed to offer community liaison and engagement work and provide treatment for common mental health disorders across a wide range of settings, including primary care, prisons, education, and secondary tier mental health teams across rural and urban environments. Care in High Volume. https://doi.org/10.1016/B978-0-323-88492-1.00012-9 Copyright © 2023 Elsevier Inc. All rights reserved.

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The greatest barrier to widespread training and implementation of psychological practitioners would be the cost of training and building systems that can support these roles safely. In the United Kingdom, we live under the care of the flawed but wonderful NHS, with access to health care that is free for anyone resident in the United Kingdom that needs it. In countries with less socialised healthcare provision, health care sometimes runs on a for-profit basis. In such an environment, we might struggle to make an argument for investment in the development of a low-intensity workforce, but that is a matter for governments to take up, not practitioners and writers!

The future of low-intensity practice in England What does the future of low-intensity therapies look like? At this point, it is impossible to say. Our hope is that low-intensity psychological interventions will mature as a modality that finds its place, equal but different, amongst other psychological professions. Although steps are being taken in that direction, including the expansion to children and young people’s (CYP) services, education, and the prison service, there are different low-intensity developments appearing around the world. Here, low-intensity psychological interventions are being offered outside of the English IAPT system and appear to be working well. Low-intensity psychological intervention has come a long way since its inception in the IAPT programme in 2007. In some ways to the benefit of patients, in other ways, less so. Our next task is to cohere as a profession, creating a community of practice by experienced practitioners who are able to lead from their lived experience of the role, including knowledge of the advantages for brief focused symptom reduction of the symptoms of common mental health problems to a wide and diverse population, as well as monitoring and safeguarding from its misuse and unethical application. For low-intensity psychological therapy to survive over the longer term in England, IAPT services must become a strong and healthy working environment. That requires system-wide self-reflection and agility, a willingness to learn from experience and an openness to change. It also requires more unity. At the time of writing, IAPT is fragmented, each IAPT team operating as an independent unit with some of those teams ignoring the recommendations in the national IAPT guidance in favour of trying to paper over gaps in local mental health service provision. What is expected of low-intensity practitioners varies from one team to the next, blurring the boundaries of the remit, limiting a more cohesive professional identity from emerging. There are already international applications of low-intensity psychological interventions as per the English IAPT programme popping up around the globe. Some of the considerations here, particularly relating to the implementation of lowintensity training and practice outside of the IAPT programme are as follows: 1. The level of training and qualification that is typical for a low-intensity practitioner. 2. If stepped care remains the preferred model for service delivery. 3. If current developments lead to an international community of low-intensity practice that takes a similar shape, form, and application to real world contexts. 4. How competency is measured. 5. If low-intensity interventions will remain exclusively CBT based or if they will shift towards a more explicitly integrative theoretical model.

Low-intensity interventions in the United Kingdom The mass implementation of low-intensity psychological interventions has not yet been mirrored in the devolved UK nations. Northern Ireland, Scotland, and Wales are all taking steps towards implementation and are all at a different stage of progress and using different training models. It seems likely that the eventual outcome will be a similar curriculum for the education of low-intensity psychological practitioners in all of the UK nations. ●

●

NHS Scotland has recently implemented the Enhanced Psychological Practice programme, which offers accredited training equivalent to the English Psychological Wellbeing Practitioner programmes that is available for public and third sector staff in primary care settings. In Wales, there are moves towards providing accredited training following something like the English curriculum. Welsh healthcare recruitment vacancies demonstrate that there is a recognised need to provide roles similar to the Psychological Wellbeing Practitioner, even if that role looks slightly different in a different national context.

If we remove the IAPT standards as the benchmark for a successful provision of low-intensity service, the utility of the role increases. What we do know reliably from outcome data and qualitative patient and healthcare partner feedback is that low-intensity practitioners demonstrably relieve suffering in the populations that they serve. Whether that equates to meaningful clinical recovery or a ‘cure’ for mental illness or disease is debatable, but we are worth having around.

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Northern Ireland Northern Ireland was the first devolved region to implement low-intensity practitioner training in the United Kingdom. The same economic and clinical arguments were made in Northern Ireland as in England for the role of the Psychological Wellbeing Practitioner. Dr. Orla McDevitt-Petrovic is a British Psychological Society accredited Psychological Wellbeing Practitioner and supervises trainee PWPs and is a lecturer on the MSc in applied psychology and psychological therapies at Ulster University. When she speaks about the development of psychological practitioner training in Northern Ireland, she places an emphasis on the availability, utilisation, efficiency,

and equity of psychological care provision. Outcomes are not just measured against a recovery target, although Orla and her colleagues did demonstrate that ‘the IAPT service model is clinically effective in the NI population’ (2018). Ultimately, the goal of training low-intensity psychological practitioners in Northern Ireland is to improve access to timely and suitable care. Orla is clear when she describes that the Psychological Wellbeing Practitioners working at the primary care level have been helpful in reducing suffering within their communities, and employment opportunities for PWPs in Northern Ireland are growing steadily.

Qualification and training In the summer of 2021 Health Education England (HEE), the body that currently provides the funding for IAPT practitioner training places announced that if you took a place on one paid psychological professions training course, then you would not be eligible to receive funding for further training programmes until you had been qualified for at least 2 years, this included funding for the professional doctorate in Clinical Psychology (DClinPsy), not part of the IAPT programme, but a common aspiration for trainee practitioners entering the low-intensity IAPT training programme. In both of our opinions, we feel the decision by HEE is reasonable and we both support this position. After all, the investment provided by HEE for one trainee low-intensity practitioner to access a training course is a minimum of 4000 pounds, throw a salary of around £25,000 per year, per trainee on top, with more than 30 institutions running one to two training cohorts per year with cohort sizes varying between 20 and 100 or more trainees, these costs soon add up, into the tens of millions each year. At the risk of sounding harsh, the cold reality is that those training places and salaries are not funded by the NHS to help individual people to attain their career aspirations in the psychological professions. The NHS does fund these courses to fulfil forecasting in psychological healthcare needs within the wider general population. Essentially, we need each of those practitioners who accept funded training places to be in clinical practice at the end of their training, and, given the taxpayer has funded those places, need practitioners to remain in those roles for a period of time afterward. The bottom line is that funded training and salaried placements mean that we need to see a return on what was intended for this investment to help the NHS meet the ever-growing demand for psychological support for those who struggle with the symptoms of depression and anxiety. Of course, access to funded training routes is essential to increasing the diversity of the practitioners within the role, to enable equitable access to careers and training that may be entirely out of reach for those who would have to otherwise self-fund. Yet, if we consider there are some who undertake low-intensity training, to then go onto high-intensity CBT training, to then go on to Clinical Psychology training in rapid concession, 5 years of training fees, 5 years of training salaries on different bandings of the NHS Agenda for Change (AFC), the bill to the public purse for each of those trainees begins to stack up into the hundreds of thousands of pounds per individual trainee. As we see it, the announcement from HEE regarding breaks between funding is simply to ensure that people are appropriately utilising funded training places to serve the function and purpose of that funding for each of those professional disciplines, to meet patient needs, as opposed to practitioner career ambition. That said, some of the concerns raised in response to the HEE announcement were legitimate. For example, there has always been a recommendation that services who host trainee low-intensity practitioners should make sure that they are able to offer full time permanent contracts after the qualification is complete. Many services can’t make that commitment because of failed negotiations with their commissioners. There are also services who exploit the funding of trainees to acquire staff year after year with no intention of retaining them once qualified. Trainees in those services are commonly asked to fulfil duties outside of their core role, in many cases being asked to act as a point of triage to the broader mental health (primary and secondary care) system. In one rather bizarre example, we had trainee practitioners working as a receptionist in an administration team, the service claiming that this was part of their training contract (which, given the training places are funded by HEE, it is currently not). Essentially, amongst those who are intending to use the role as a stepping stone to their longer-term career, there are many who apply for the low-intensity practitioner role and experience harm within their training year. Hence, this gives us serious pause for thought at limiting the opportunity for alternative NHS funded training courses to 2 years, effectively risking practitioners becoming trapped in the role whilst working in poor conditions. Essentially, this then becomes a difficult dilemma to balance.

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How will training be funded outside of the NHS? So why are we talking about all this in a chapter aimed at discussing international applications of low-intensity practice? Why all the doom, gloom, and politics? Of course, we had always known to some degree that many of our low-intensity candidates in the English programme pursued employment in the role because it was a step towards further funded training. But our curiosity here being, how would this work outside of the NHS? Say for example, in systems where there is limited or no free at the point of access healthcare system or funded healthcare training? Who applies for low-intensity psychological therapies training, then?

James: Who would be the typical person that you would envision as applying for low-intensity training outside of the UK NHS programme? Liz: So, for example, people with a physical or mental health core profession, nurses, social workers, support workers, doing this is additional competency training alongside their core profession, perhaps? James: Because, I’m thinking here of my own career, and, say that if I was born in the United States, and starting out. Say, I wanted to get onto a PhD or whatever the training for a psychotherapist or psychologist looks like in that country, and there was no funded training route, I would be thinking about how best I would use what (if any) available funding I had to reach my career goal. If low-intensity therapy was not the career I wanted, then would I invest in it out of my own pocket? Unless it was required or advantageous to my eventual career goal, similar to the UK system, then, being very honest, for me, I would be very unlikely to spend the money on the low-intensity training course. Liz: I still think there will be a group of people, again back to those whose core profession is physical healthcare, where they are perhaps wanting to incorporate low-intensity psychological skills within their offer. I am a big fan of the idea of dual training leading to holistic physical healthcare. I talk about that in the chapter on long term conditions. But I also wonder if there is scope for this to be a part of someone’s role outside of healthcare. Maybe even expanding this to office workers with an interest in staff wellbeing? James: Okay, sure, but what about low intensity as a full time professional role, requiring a full time training course, clinical placement and supervision? If you were a private company in the United States, for example, offering a placement to the training course, who are the people that you would want to attract into those training programmes? Liz: Well, you could also do something more radical, swing it away from the typical psychology graduate, perhaps people with an interest in psychological therapies, but perhaps not with the background in psychology. Maybe people who are currently hairdressers, bar tenders, cafe owners, but want a career in a clinical mental health role? Essentially, people who have good interpersonal skills, and transferable common factor skills in being able to relate and speak to people. James: So the key thing being interpersonal skills rather than knowledge of psychological theory? Liz: Well, yes, but then you would say that, James. James: Of course! But I think there would be a requirement to have both?

Liz: But why not? I mean, I clearly recall you saying in practically every one of the training sessions we have done together, that the most effective low-intensity therapist you have worked with was an ex bartender. James: Yes, I said that (laughing). Liz: Yes, and what I am getting at is that you really do not need a first-class bachelor’s degree in psychology to do this role. We can train everything you need to know on the 1  year training programme. My degree was in literature! I only ended up in the programme because I was patient on the long term health conditions management course. My point being that in the current IAPT remit we have always aimed it at attracting psychology graduates with their eyes on training as a psychologist, but retention has, and still is, horrific, because they jump ship once they get onto a doctorate or psychotherapy training. Why not open this up to people who want to change careers and have this as their career, or to enhance and diversify what they currently do? I mean, who knows how that would play out? But there can’t be any less longevity in it that we currently have now in the English IAPT system. I mean, we have the apprenticeship programme that is steadily coming through, and some of the trainees entering through the undergraduate route have been exceptional. James: That is true, I remember a couple of them from the Bradford course. Liz: I know, if we think of the likes of [name redacted for anonymity], you can’t teach those interpersonal skills in a classroom setting, he brings those skills with him already. James: So, essentially you are saying that if the role moves away from trying to attract those with a psychology background, for example, in the United States, those who want a clinical role, but not aspiring to a PhD in psychology, or psychotherapy training? Liz: Well, kind of, yes. Not necessarily excluding people who might want to start out their career in low intensity and go on to further training, but opening this up to anyone with good human skills and an interest in helping people with common problems such as anxiety and depression. There was already a potential solution in the works in the United Kingdom, and this brings me back to my original point about qualification. The idea of apprenticeships has been in the air for a whilst now. An apprenticeship route to qualification would open up opportunities for more people who see the low-intensity role as a high aspiration to achieve their career ambition. The idea is that people who might not have academic qualifications but who have got extensive, enriching, life experience could get access to a Level 6 (equivalent to undergraduate) course, or top-up if already holding a qualification in a core profession.

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Stepped care as an international model for service delivery One of the key elements following the implementation of the low-intensity arm of the IAPT programme is that it currently operates within a stepped care system. As we have described throughout this book, this had more recently led to a wide scale implementation of low-intensity psychological practice outside of the scope and aim that the low-intensity programme was designed to work with. Similarly, its misuse as a way of managing waiting lists and obtaining the most throughput for the least costs, whilst being precariously balanced on a statistical evidence base but with longer-term outcomes being less advantageous, based on the small amount of research available. One of the issues here is that the initial investment in building the low-intensity programme was that of cost savings. Therefore, outside of a free at the point of access healthcare system such as the NHS, how does this translate to countries where the private sector is dominant?.

James: Okay, say for example I am a private healthcare provider outside of the United Kingdom. What are the added benefits for my company that would encourage me to set up a low-intensity therapy arm to my existing business model? Why would I not just simply continue to employ the workforce that already exists, e.g., qualified counsellors, coaches, psychologists, and psychotherapists? Liz: Do you mean where would low-intensity fit within their existing model? James: I guess what I am asking is what is in it for the private sector? Again, referring back to the United States for example, insurance companies? What do you think will be the incentive for them to buy into low-intensity psychological therapy? Liz: I think it’s again, I don’t want to devalue the role, because I obviously hold low-intensity interventions in high regard, but the economic principle is similar to that of a pound shop. Actually scrap that! Terrible example! James: Keep going, it’s interesting. Liz: I mean, the idea of a pound shop is that you sell lots of things for very little money. Low-intensity interventions were developed in recognition of the fact that a high proportion of the people in our society suffer from what can be debilitating difficulties with anxiety and depression. The volume of those needs is what prompted the initiation of this approach. It has a knock on effect to society at large and it also has an economic impact. In the United Kingdom it’s about a quarter of the population that might have low level depression or anxiety disorder at any moment and every one of those people is finding life harder than it needs to be. We want those people to get help quickly and for that help to be free at the point of use. Most people could not afford that kind of help if it were not free on the NHS. But if we are thinking economically outside of the NHS, a quarter of your local population getting access to low cost treatment is going to net you a lot more as a provider than a small

portion of your population who can afford to pay high fees. If you are a company needing a financial incentive to implement it, that is. James: I think it’s an interesting argument, but doesn’t this take us straight back to the problems we see in the NHS? In terms of the low-intensity role being set up as a cost saving exercise. It was only really by chance that the benefits of the low-intensity programme have appeared, in that it is being found to match other modalities in terms of its shortterm efficacy, but, for me, the economic argument for its inception is not where the value of low-intensity practice is. For me, this comes back to problems with outcomes and cash over care. For example, in the United Kingdom, it’s often been used to prop up underfunded systems and all we have ended up with is a high volume of people at the front door with many of those people being inappropriately treated, or not getting access to appropriate treatment. Liz: I do think that one of the unanticipated consequences of the IAPT programme was that we have been forced to recognise the volume of need for more psychological therapies. For example, even when I started training in 2010, PTSD was thought of as a rare disorder that people with combat experience might present with. Now we know that it isn’t very rare and that people can experience PTSD after childbirth, after a car accident, after domestic abuse… What we’ve done is train thousands of people in what the range of mental health conditions look like, we’ve put them into Primary Care and made them easy to reach. Now that people are available with the right knowledge and the time to ask the right questions the prevalence of the more complex mental health conditions is becoming apparent. Which then raises the responsibility to provide appropriate care for those people, and low-intensity interventions might be able to do some good but isn’t truly sufficient to meet the needs of that population.

The wider world So far, we have kept the majority of our focus on western societies in the global North because that is our personal context and experience. However, some of the most exciting and innovative developments in low-intensity psychological care happen outside of that context. There is a rich and longstanding literature around the development of psychological care in low and middle-income countries that we do not have scope to do justice to here—that is another book that we would be eager to read. Here, we will simply acknowledge that these are not new developments. The example of international low-intensity

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developments that people bring to our attention most often have been the ‘friendship benches’ in Zimbabwe, where ‘grandmothers’ have delivered problem-solving interventions for more than 20 years (Chibanda et al., 2016). What appeals to us about that intervention is its organic nature; communities destigmatise mental health conditions and mental health care by using what is already normal and present within their day to day lives. Using what was already there and effective, with a light or absent touch in terms of the education that comes in from outside. There can be an implication in some of the published literature that is based on western developments of low intensity interventions, that a direct translation or copy of what we have developed in England and other Global North nations would be the best provision of care around the world. This is not in-line with the principles that we have proposed in this book. Reporting on the need for reform in Ugandan mental healthcare, Molodynski et al. (2017) eloquently write that a mental healthcare model ‘need not be a watered down or inferior version of that in wealthy countries, but something genuinely different—grounded in communities, minimising the need for institutional care, and linking closely with functional recovery through work and family networks’.

Core principles of low-intensity psychological practice In the various chapters throughout this book, we have attempted to provide definitions of what we would consider to be the defining characteristics of the low-intensity psychological interventions. These are compiled here: 1. The patient is the agent of change, and the practitioner facilitates and encourages change. We aim to build a sense that the patient can act to change how they feel (Lovell et al., 2008). 2. Good low-intensity practice integrates behaviour change models and techniques (Pilling et  al., 2015) from any evidence-­based modality that can be adapted to meet the needs of the community that the practitioner serves. 3. Co-production of services, working in partnership with family and caregivers as well as patients (Taylor, 2003). We should always aim to improve social integration and reduce isolation. 4. Integration with existing healthcare pathways and team-working with physical and mental healthcare practitioners (England and Helen, 2007). Low-intensity interventions work best and most safely when they are provided in collaboration with other types and intensity of care. 5. Low-intensity psychological interventions can be effectively delivered through any communication method. The integration of technology either for education or to facilitate communication does not have a negative effect on outcomes and can increase the accessibility of services. 6. ‘Human support increases the probability of success’ for low-intensity interventions (Kuroda et al., 2021); the balance of interpersonal and engagement competencies with competencies in specific low-intensity interventions needs to be considered during recruitment and training of practitioners. 7. This approach is less burdensome for the patient to engage with than longer-established therapeutic modalities; it asks less of them in terms of emotional labour, time, money, and commitment. 8. Low-intensity psychological interventions are time-limited, and this is transparent from the outset; this should not equate to a rigid ‘session cap’ where a patient is refused further appointments or contact after a predetermined number of contacts with a practitioner. 9. Time-limited contact with the Psychological Practitioner, you don’t just get a short course of treatment, but appointments tend to be shorter than the traditional ‘therapeutic hour’. Again, flexibility to the local context and the individual person should be offered. 10. Use of education that might take the form of written, video, or audio educational material and/or worksheets and apps to enable the patient to understand their problem, and guide the work that the patient does in-between contacts with the practitioner. 11. A low-intensity practitioners’ goal for treatment is always to transfer knowledge and skill and power from the practitioner to the patient, building patient self-efficacy with the consequence that there is less need for support from a practitioner in the future. 12. Low-intensity practitioners are collaborative: we practice what we do ‘with’ our patients, not ‘on’, ‘at’, or ‘to’ them. 13. Based on a holistic understanding of the patient and their context, and geared towards enabling the patient to achieve a goal that matters to them, treatment is not ‘diagnosis’ driven and the patient decides what ‘feeling better’ means. 14. Delivered within integrated systems so that the patient is supported to access the right level and type of care with meaningful choice in what is on offer. 15. Low-Intensity Psychological Practitioners can’t act in a ‘free for all’ they are required to work with interventions that are supported by research evidence of a high standard.

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James: I think the main advantage of low-intensity therapy is that it can provide swift relief from mild or recent problems with anxiety and depression and can be delivered at a pace, rate and intensity that doesn’t feel like ‘big T’ Therapy. Essentially, therapy for people who don’t want or need a counsellor, psychotherapist, or psychologist. The problem as I see it though, is differentiating between self-help, given that this is freely available online and saturates the shelves of most bookstores, versus ‘guided’ self-help, where the evidence for its use is primarily as part of a stepped care system to support throughput in the NHS in England. I imagine there will be questions raised by providers outside of the NHS about why this would be worth developing in other places. Liz: If we think about stepped care, some of the ways it has been used in the United Kingdom has been to the patient’s disadvantage and sometimes it’s been used coercively, but

I still think that there is something important about progression in a care system that is helpful. Part of the clinical judgement that you have to make is about when we need to step off and say ‘that’s not where I can work with you’, and we need to be able to offer access to someone who can. Still, there is something so fundamental about what we can offer. I know that some of our colleagues—and I certainly do this—we teach those basic CBT principles to our children. If we embedded this idea of simple tools and information to help children to understand their thoughts, emotions and behaviour into the Primary and Secondary school curriculums wouldn’t that be amazing? The Children and Young People’s Wellbeing practitioners and the Educational Wellbeing practitioners are doing great work but it would be exciting to offer some of these ideas before a person starts to have problems, instead of responding afterward. That’s a big ask though, and a different field of work to ours.

Targets There is a balance to strike between providing evidence-based and standardised psychological interventions and adapting to the needs of the populations that you serve. England is a geographically small region but the density of the population means that the small area contains a great variety and richness of culture and experience. We train our low-intensity psychological practitioners to a standard curriculum—inculcating competencies in the ‘common factor’ therapeutic skills and a baseline of the most effective evidence-based treatment interventions that typically derive from cognitive and behavioural approaches. We know that these approaches, appropriately adapted, have acceptability in different parts of the world outside of England. This is evident in the work that the British Association of Cognitive and Behavioural Therapies do with professional organisations throughout Europe and the Middle East. During and after training, low-intensity practitioners are required to take those skills and treatment principles and make them useful for the diverse populations that they work within. The leap from a simple introduction to the principles of the treatments to the demands of real-world practice creates a gap that allows room for unsafe clinical drift as well as for creative adaptation. What happens there is determined by the quality of the supervision that is provided and the reflective ability of the practitioner. An element of agility was built into the IAPT system. There are commissioning guidelines in the IAPT Manual but commissioning of a local IAPT team is through the GP commissioning consortia—the GPs decide what their local population need from their IAPT team and they buy that in. This flexibility is essential—there is no ‘one size fits all’ model for the design of psychological services. Services would ideally be co-designed with representatives of the local community who can guide commissioners and practitioners to deliver what is most needed. Co-production is uncommon in IAPT, not universally, but in some places there is a narrative that, because we deliver ‘evidence-based’ services any input from patients would necessarily reduce the quality of what we provide. Essentially, that IAPT knows best and patients do not know enough about psychological care to have a say. Any flexibility that we have in commissioning is not reflected in a flexibility of targets. Where the commissioning priority is to engage one particular community in psychological care provision, practitioner time might need to be spent on building relationships with that community and liaising with networks of health and social care provision to ensure joined up and accessible services. This is at odds with an access target that puts an emphasis on through-numbers. Practitioner time that is not spent delivering contact time is wasted time—or so a target-driven culture would tell us. We know from the available IAPT data that outcomes from IAPT treatment vary depending on the race and ethnicity of the patient, yet we have no targets that would prompt IAPT services to address this and deliver services that would produce equity of outcomes. As long as an overall recovery rate of 50% is achieved, the volume of appointments delivered does not slack and waiting times do not creep up, there is no motivation to address more fine-grained targets. Doing the necessary work to ensure equity of access and outcomes with the available staff would inevitably mean that fewer appointments were offered, in the short to medium term at least. In short, to make the necessary changes to protect practitioner wellbeing, improve staff retention, and design and deliver services that are useful for the whole population, we would need an amnesty from the current targets. When targets are

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reintroduced, they would need to reflect the unique requirements of a local community and this would require immense adaptability from practitioners and careful supervision. At the same time, every practitioner would naturally strive to provide services that give high quality and effective care (recovery) to as many people as possible (access) as quickly as possible (waiting times). We would do that not because we were forced or required to but because that is the kind of service that we want to deliver.

Lessons learned from IAPT To accrue a workforce with the necessary training and experience in low-intensity interventions to make widespread implementation sustainable, low-intensity practice needs to become sustainable in the long term for individuals. In England, problems with retention arise from a combination of individual career aspirations, unsafe work environments that threaten the practitioner’s health whilst they provide care, and lack of recognition and reward from the work. Some of these tensions show up in the debates about our professional status. Although, in some respects, the debates about professional status that feel so important to psychological practitioners in the United Kingdom are meaningless. Professional status provides recognition of the value of the work that is done and the qualities and skill of the people who deliver this approach but it should not become a barrier to the global upscaling of accessible and effective psychological care. There are lessons to learn from the growth of the psychological professions in England. 1. Delivery within rigidly target-driven systems can be harmful, other ways to maintain quality standards should be identified. 2. Data-informed service design and data-informed delivery of care can be helpful. Session-by-session data collection can be clinically meaningful provided that this does not disrupt the quality of the therapeutic alliance during treatment. 3. Low-intensity psychological practitioners are often well-placed to build relationships with local communities that support adaptations to service delivery and reduce barriers to engagement with care. They should be given time and authority to do so. 4. To retain staff and accrue expertise in this way of working, the conditions that practitioners work in should be psychologically and physically safe and rewarding. 5. High-quality supervision is paramount for patient safety, practitioner wellbeing, and to maintain standards in care.

Back to barefoot As we bring this book to a close, our final thought brings us back to the very beginning of low-intensity psychological care: those principles of the ‘barefoot therapist’. Ultimately, low-intensity, high-volume psychological care doesn’t have to be married to any one service design or therapeutic approach. The original idea proposed in Chapter 1 of this book was that the most common mental health problems in a community could be identified. People from within that community can then be trained quickly to deliver the best available evidence-based care for those problems and that care can be delivered to a high standard. In essence, this is a workforce of specialists who don’t have the same scope of practice as a counsellor, psychotherapist, or psychologist, but who can deliver what is needed to effectively target and reduce the suffering caused by the difficulties that are most commonly encountered in a particular population or community. Low-intensity psychological high-volume care, if applied flexibly, ethically, and reflexively, is a pragmatic development with a high potential for global application, and an exciting future.

References Chibanda, D., Weiss, H.A., Verhey, R., Simms, V., Munjoma, R., Rusakaniko, S., et al., 2016. Effect of a primary care-based psychological intervention on symptoms of common mental disorders in Zimbabwe: a randomized clinical trial. JAMA 316 (24), 2618–2626. https://doi.org/10.1001/ Jama.2016.19102. England, E., Helen, L., 2007. Implementing the role of the primary care mental health worker: a qualitative study. Br. J. Gen. Pract. 57 (536), 204–211. Kobori, O., Nakazato, M., Yoshinaga, N., Shiraishi, T., Takaoka, K., Nakagawa, A., Iyo, M., Shimizu, E., 2014. Transporting cognitive behavioral therapy (CBT) and the improving access to psychological therapies (IAPT) project to Japan: preliminary observations and service evaluation in Chiba. J. Ment. Health Train. Educ. Pract. 9, 155–166. https://doi.org/10.1108/JMHTEP-10-2013-0033. Kuroda, N., Burkey, M.D., Wissow, L.S., 2021. Discovering common elements of empirically supported self-help interventions for depression in primary care: a systematic review. J. Gen. Intern. Med. 36 (4), 869–880. https://doi.org/10.1007/s11606-020-06449-y.



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Lovell, K., Richards, D., Barkham, M., Sibbald, B., Roberts, C., Davies, L., et al., 2008. Developing guided self-help for depression using the Medical Research Council complex interventions framework: a description of the modelling phase and results of an exploratory randomised controlled trial. BMC Psychiatry 8. https://doi.org/10.1186/1471-244X-8-91. Mental Health Commission of Canada, 2018. Expanding Access to Psychotherapy: Mapping Lessons Learned From Australia and the United Kingdom to the Canadian Context. https://mentalhealthcommission.ca/. Molodynski, A., Cusack, C., Nixon, J., 2017. Mental healthcare in Uganda: desperate challenges but real opportunities. BJPsych Int. 14 (4), 98–100. https://doi.org/10.1192/S2056474000002129. Pilling, S., Hardy, R., Newman, R., Cape, J., Greenfield, K., Roth, T., et al., 2015. Report of the Psychological Wellbeing Practitioner Review. University College London, Centre for Outcomes Research and Effectiveness, London. Retrieved from: https://www.ucl.ac.uk/pals/sites/pals/files/pwp_review_-_interim_report.pdf. Taylor, A., 2003. The primary care programme of the National Institute for Mental Health in England (NIMHE). Prim. Care Ment. Health 1, 1–3. World Health Organisation, 2022. World Mental Health Report: Transforming Mental Health for all. Licence: CC BY-NC-SA 3.0 IGO.

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Index Note: Page numbers followed by f indicate figures, t indicate tables and b indicate boxes.

A

CEDAR, 43 Centre for Clinical Interventions, 43 Children and young people’s (CYP) services, 225 Cognitive analytic therapy (CAT), 37, 55 Cognitive behavioural therapy (CBT), 6, 44, 51, 55, 85 COM-B model, 44–45, 50 Computerised cognitive behavioural therapy (cCBT), 6 Condition management programmes (CMPs), 8 “Conveyor-belt” approach, 179

gender and sexual diversity, 118 outcomes, therapeutic paradigms, 114–115 visibility, reducing access barriers, 115–116 LGBTQ+, therapy as, 115 low-intensity supervision, 124–125 minority stress modelling, 113 reflective learning task, 111 service policy, adjustments, 120 social relationships, power and intersectionality, 113 therapeutic boundaries, 131 typical LICBT psychoeducation material, 128 General Data Protection Regulation (GDPR), 203 GetSelfHelp, 43 Graduate mental health workers (GMHW), 8–9 Guided self-help cognitive analytic therapy (GS-CAT), 36–37 Guided self-help (GSH) material, 6–7, 27, 63, 161

D

H

Anxiety, 173–174, 183–184

B

Barefoot therapy, 4 British Association for Cognitive and Behavioural Psychotherapies (BABCP), 166, 214 British Psychological Society (BPS), 214

C

Doncaster IAPT demonstration site, 11

England, low-intensity practice, 225–226

Health and Care Professions Council (HCPC), 213 Health Anxiety Inventory (HAI), 30 Health Education England (HEE), 226–227

G

I

E

Gender and sexual diversity active inclusion vs. inactive tokenism, 116–117 affirmative practice, 116 assessment of risk, 119 barriers to engagement (COM-B), 120–121 “conversion” therapy, 112 deficits vs. strengths, 130 equality of access vs. equity of access, 128 guided self-help, 126–128 adaptations in, 128 high-intensity therapy, 123 lesbian, gay, bisexual, and transgender (LGBT), 111, 131–133 access and outcomes, UK psychological services, 114 age, LGBT experiences, 112–113

Improving Access to Psychological Therapies (IAPT) program, 1–3, 28 into action, 14 evolution, 4–5 individual guided self-help, 35–36 local IAPT service, 28 locked doors, 27 low-intensity element, ingredients for, 12 low-intensity intervention, 32–33 progressive stepped care, 29 challenges with, 29–30 evidence for, 31–32 psychoeducational groups, 33–35 re-humanising systems, 36–37 revolving doors, 27 right doors, 26–27 service suitability criteria, 28

stratified stepped care, 29 success, definition of debate on, 25 low-intensity intervention, 32–33 routine outcome measurement, 33 wellbeing business, 26 wrong doors, 26 International applications barefoot, 232 evidence-based psychological care, 225 funded healthcare training, NHS, 227 IAPT, 231–232 low and middle-income countries, psychological care in, 228 low-intensity practice in England, 225–226 Northern Ireland, 227 psychological practice, core principles of, 229–230 in United Kingdom, 226 mental health disorders, 225 qualification and training, 226 stepped care psychological care services, in primary care, 225 service delivery, 228 targets, 230 International Coaching Federation, 162 Interpersonal process anxiety, patient engagement, 183–184 avoidance and control, 186 barriers, 185 cheerleaders, 187–189 devaluing between groups, 182–183 idealising and devaluing process, 180–181 LICBT training, personal motivation for, 179–180 low-intensity psychological therapy, 182 low-intensity supervisor and university marker, 184 low therapeutic alliance, 185–186 problems with, interpersonal skills, 194–195 quarterback, 189–191 reflections, 195–196 reflective practitioner, 191–193 splitting, defence mechanism, 180 therapeutic working alliance, 184 Intervention, definition of, 41–42. See also Low-intensity psychological interventions

235

236  Index

K

outcomes, 21 typical trainees, 18

Key performance indicators (KPIs), 26

L

Lesbian, gay, bisexual, and transgender (LGBT), 111, 131–133 access and outcomes, UK psychological services, 114 age, LGBT experiences, 112–113 champion, 117–118 construction and deconstruction, psychotherapy, 112 gender and sexual diversity, 118 outcomes, therapeutic paradigms, 114–115 visibility, reducing access barriers, 115–116 Long-term health condition (LTC), 80 Low-Intensity Cognitive Analytic Therapy (LICAT), 210 Low-intensity cognitive behavioural therapy (LICBT), 32–33, 51 definition of, 51t Low-intensity person-centred counselling, 56 Low-intensity psychological interventions, 21–22 barefoot therapy, 4 base/apex, 11 benefits of, 3 bibliotherapy, 6 common mental health disorders, 5, 5t delivery methods, 2t evidence, economics, and serendipity, 13–14 graduate mental health workers (GMHW), 8–9 group work, 7–8 guided self-help (GSH), 6–7 guidelines, gaps in, 21 high-volume, 9, 18–19 high volume and low intensity, 16–17 informed consent, 15 “mental health work”, 2 National Institute for Health and Care Excellence (NICE), 9–10 NICE guidelines, 12 nurse therapists, 4 outcome measures, 16 phasing, 5–6 predictable problems, 17–18 psychological professionals, 16t psychological safety, 21 psychological therapies, in primary care mental health services, 15 self-help, 6 resources, 7 social context, 19 stability, 18 stepped care, 10, 12t stratified care, 10 supervision, 19 talking therapy, 5, 15 training and competencies, 14, 17–18

M

Mind Over Mood, 7 Mood Juice, 43

N

National Institute for Health and Care Excellence (NICE), 9–10 Northern Ireland, low-intensity practice, 227

O

Overcoming Depression, 7

P

Persistent physical symptoms (PPS), 78 Physical healthcare, low-intensity psychological interventions in, 82–84 acceptance, 102–103 acute illness vs. chronic illness, 85, 86–87t allied health professional, 79 assessment, 96 biopsychosocial model, 79, 89, 97 CBT-based low intensity program, 81 circle of care, 92–93 collaboration, 106b complicated anxiety, 92 condition self-management and, 98 culture clash, 91 depression vs. physical disability, 101 disease and illness, 79 dual-trained practitioners, 85 emotional management, 99 five areas/five part model, 79 formulation, power of, 96b functional equivalence, 104 functional neurological disorders (FND), 88 health, 79 IAPT long-term conditions expansion, 80 implementation, 94–108 integrated care, 106 integration, 79, 93–94 intersectional lens, 82 kindness, 105 levels of response, 84 limitations, 105 long-term health conditions (LTC), 77–79 low-intensity practitioner, 81, 107 medically unexplained symptoms (MUS), 78 medical management, 99 mental health in, 80 multistrand interventions, in LTC, 103 NHS planning document, 80–81 NICE guidelines, 89 pacing, 104 physical and mental healthcare, 88 post exertional malaise (PEM), 100b proportionate response, 92

quality of life, 79–80 reciprocal support, 106 recovery measure, 96b role management, 99 self-help material, 84 self-management, 100 specialisation, 81 supplementary interventions, 102 valued activity, 104 “wellbeing”, 80 WWIM model, 96–97 Professional identity anxiety disorder, 216 clinical interventions, 216 cognitive behavioural therapy (CBT), 209–210, 219 core professions, 213 counselling and psychodynamic therapies, 219 in IAPT, 217–218 depression, 218 direction of growth, 214 “enhanced psychological practitioners”, 209 evidence-based costs, 217 evidence-based interventions, 207–208 HEE announcement, 220–221 IAPT, 207, 209–210 imposition, 215 integrity, 213 interpersonal skills, 222–223 knowledge, skills and attitudes, 214 low-intensity interventions, developments of, 210 low-intensity practitioner (LIP), 211 referrers, 212 low-intensity psychological interventions, 207 definition, 210–211 low intensity therapist (LIT), 208, 211 NICE, 218–219 petition, 221 prediction and experience, 211–212 professional status, 212–213 progression, 213–214 psychological professions network (PPN), 208–209 registration, 208, 223 saturation, 220 service leadership perspective, 222 status and inclusion, 221–222 stepped care systems, 216 trainee practitioner recruitment, 219–220 tribes, 215–216 “wellbeing practitioners”, 208 Progressive stepped care, 29 challenges with, 29–30 evidence for, 31–32 Psychological wellbeing practitioner (PWP), 1, 26 burnout, 147–148 career progression, 152 clinical and operational leadership responsibility, 152 clinical drift, 143

Index  237

comparative deprivation, 140–141 compassion fatigue, 147 complaints and whistleblowing, 149 handover arrangements, 151 high-quality psychological care, 155 high-volume, low-intensity work, 138–139 interpersonal elements, of low-intensity work, 152 loss of reward, 148–149 low-intensity practitioners, 137, 140 micromanagement, 144–145, 157 negotiating targets, 153 private organisations, 149–150 progression frustration, 145 recognition, 153–154 recognition, reward and respect, 139–140 responsibility, 151 sick leave, 148 specialisation, 152–153 stepped care model, 143 supervision, 152 supervision and reflection, 143 target-driven, IAPT program, 143–144 trauma, 146–147 vicarious trauma, 147 Psychological professions network (PPN), 208–209 Psychological safety, 159

Q

Queer theory, 111

R

Reflective practice, 49 Re-humanising systems, 36–37

S

Self-Help Access in Routine Primary (SHARP) Care, 7, 43 Self-practice/self-reflection strategy, 49 Social contexts, 76 adaptations and flexibility, 74 anger and IAPT, 64 and low-intensity intervention, 63–64 assessment phase, 66–67 clinicians, 75–76 “common mental health disorder”, 61 complicated maintaining factors, 68–69 core conditions, 74 disclosure, 71 dissociated systems, 69–70 ending treatment, 73 equitable outcomes, 61 low-income areas, assessment challenges in, 61 low-intensity psychological intervention, 73 mental health problem, 61 motivation for change, 70–71 power and prognosis, 66 psychological therapy, 73 second (extended assessment) session, 67 service suitability assessments, 61

social disorder, 62 social neglect, 62 suitability people vs. systems, 64 problems with, 63 supervision, problems in, 75 informed care, 75 South Yorkshire Condition Management Programme (SYCMP), 8 Stepped care model, 10, 12t, 28, 143, 216 Supervision case management vs. clinical supervision, 198–200 access, 199 recovery, 199–200 waiting times, 199 challenges, 202 clinical skills groups, 200 contracts, 202 high-volume case management, function of, 200 leadership, 200 vs. line management, 198 line management vs. clinical supervision, 197 low-intensity supervision, 203 challenges, 201–202 implementation, clinical supervision, 203–204 variation within, 201 low-intensity supervisory model, 202 in England, 200–201 mentoring vs. clinical supervision, 198 monitoring fitness to practice, 198 patient and practitioner, 203 psychological professions, functions and use of, 197 recording sessions, 203 seven-eyed model of, 204f supervisee and supervisor, 203

T

TalkPlus, 43 The Mental Health Handbook, 7 Therapeutic boundaries challenges, with engagement, 161 clinical drift, 165 cognitive behavioural therapy (CBT), 160 countertransference, 167 drift, intentionality of, 166 empathic and compassionate relationships, importance of, 175 ethical low-intensity relationship, 168 exiting defensive practice, 171 IAPT system relational challenges, in England, 173 laboratory vs. home testing kits, 164 low-intensity CBT (LICBT), 160 approach, 168 low-intensity coaches, 162–163 low-intensity psychological practitioners, 163–164 low-intensity relationship, 166

ethical relationships in, 168–171 patients, drop-out of treatment, 161 professional boundaries, in human services, 159 relational boundaries, in systems, 174–175 relational drift, 161–162 relational dynamics, of systems, 172 ruptures, in systems, 173–174 therapeutic content and process, 162 therapist effects, 160 transference, 167 and countertransference, 166–167 relationship, 167 upward vs. downward drift, 165–166 wing mirror, 159–160 The University of East Anglia, 43 Trainee psychological wellbeing practitioner (TPWP), 52 Training antidiscriminatory practice, 47 assessment process, 57 behaviour-change strategies, 52 “clinical skills practice”, 46 COM-B model, 44–45, 50 “competency measures”, 48–49 competition, 52 complexity and burnout, 50–51 diagnostic labels, 58 equitable services, 47 ethical implementation, implications for, 50 evidence-based practice, 54–55 exclusion, 55 formulation, 45 free for all practitioner, 54 problems, 56–57 IAPT, clinical practice in, 53 “low-intensity interventions”, 39, 50 vs. high-intensity CBT, 51 IAPT program, 40 low-intensity practitioners, 39–40, 44 low-intensity treatment, 58–59 manualisation, first step toward integration, 55–56 manualised practitioner, 54 manualised training, 47 medication management, 40–41 new practitioners, on teaching, 45–46 paraphrasing, 53 personal practice and resilience, 53 practitioner training, 39 in IAPT, 46 principles to practice, 47 problem identification, 45 process-based CBT, 45 profession, 52–53 pro formas, 55 psychological intervention, 47 psychological professions, 53 reflective practitioner, 54 in action, 57–58 reflective space, 59 right intervention(s) or strategy (ies), 45 self-help material, 42–43

238  Index

Training (Continued) barriers, 43 sources of, 43 self-practice, of low-intensity techniques, 53 simplicity, 39

single-strand vs. multistrand interventions, 49 “social graces”, 48 solutions, 53 SPSR, 49 therapeutic “drift”, 44 training cultures, 46–47

U

United Kingdom, low-intensity practice, 226