‘Becoming a self-therapist is the real goal’

Getting psychological help when we need it can include being responsible and taking care of ourselves. The Improving Access to Psychological Therapies (IAPT) system works towards easy and free access to psychological help, and I could not be more than happy to be part of this system as a Trainee Psychological Wellbeing Practitioner (PWP). IAPT is not without its critics, but here I would like to emphasise, through my personal experience, the good qualities that the programme and the PWP role can have.

So what is a PWP, and what's it like being one? It's a simple question, with sometimes complex answers…

More than meets the eye

We are not qualified psychologists, but at the same time we use many psychological tools. There are those who see our training as more suited to the role of 'motivational coach'; there are also those who see us as 'postmen of leaflets' on mental wellbeing. I find it upsetting when people underestimate my job, because there is so much more to being a PWP. We're using those tools as treatment interventions to deal with common mental health disorders such as depression and anxiety, in a personalised way, to help people become their own therapist. 

It is a stressful, hard and emotionally tiring role. As a trainee, I have an average of 20 patients per week, and university lectures every Tuesday. The weekend is often spent studying. All this for a total of 12 months. It requires a lot of energy and effort to achieve a level of professional and clinical excellence. In a limited time, the PWP must be able to encourage hope, build a relationship of trust and provide people with practical strategies on how to deal with their emotional difficulties (e.g. see Papworth & Marrinan, 2019). That needs strong interpersonal skills and the ability to manage individual wellbeing – it is absolutely not a job for everyone.

The role of the PWP is challenging but rewarding. At the moment due to the pandemic, we are all working from home. At 9am, I turn on my work laptop and check all my appointments, which will take place either via phone or on Teams. Usually I have about five or six clients a day, some of them for a first assessment and others for providing treatment interventions. When I assess someone for the first time, it is very important that I read all of their notes or background in the in-work system where the information is securely stored. Then at the end of the evaluation, when a provisional diagnosis has been gathered, I offer treatment options based on this.

We work within the Stepped Care model (NICE, 2011) and PWPs are part of Step 2, whilst High Intensity therapists are on a Step higher. This is why it is important to assess the severity of the symptoms. If the symptoms are in the mild-to-moderate range, I usually I offer three choices, all based on the Cognitive Behavioural Therapy (CBT) approach. A client might opt for computerised CBT, where an online programme will support them through their therapy pathway; or for a group course, where they may share different experiences with others with the same condition; or finally for Guided Self-Help support, where a PWP provides one-to-one support in guiding the person through their recovery. If the symptoms are severe or the main problem is trauma-related, the client is referred to Step 3. As a PWP, I deliver all the treatment formats for mild-to-moderate symptoms, monitoring the progress of each client through specific questionnaires. And when I see – after usually six weeks of intervention – that the symptom scores are below the so-called cut-off (i.e. the person is in recovery), all the challenges and difficulties are swept away by a deep sense of satisfaction. Then there is no better feeling than turning off my work laptop at 5pm.

A wealth of simple strategies

First, we need to start from the assumption that any therapeutic intervention is fundamentally based on the positive relationship established between the patient and the therapist. How is it possible to create this alliance with someone you will be seeing for a short time? From personal experience, it is absolutely not easy, but also not impossible! For example, I remember an old lady who came to our service with depressive symptoms. At our first appointment, it was difficult to build a confidence with her as she admitted she was a little dubious about psychological therapy, and was scared to show her vulnerabilities to a stranger. It was important for me to normalise the situation, making her understand that it was OK to be scared. My role would be to sincerely support her main emotional difficulties. She slowly opened up, and at the end of our treatment sessions she even offered to bake me a cake once the restrictions on Covid-19 eased!

That was just one case, but there are certainly a series of interpersonal skills that can create a certain harmony right from the first contact with the patient. Once this interactive affinity is achieved, it is much easier to establish concrete expectations about the treatment. As the founding fathers Ellis and Beck taught us, CBT is based on the idea that through daily practical exercise the patient has the possibility of regaining their own mental wellbeing. All of this is do-able in a couple of months (sometimes even less) of treatment sessions.

I like to think that our role has very high recovery potential if exploited to the maximum. As the saying goes: 'Give a man a fish and he will eat one day. Teach him to fish and he will eat all his life'. The true essence of the clinical work of a PWP is not in having the immediate solution to all problems, but rather having a wealth of rather simple strategies that could give a person the possibility to manage their emotional difficulties. Becoming a self-therapist is the real goal. The PWP is like a guide who works with people to understand what is happening in their life, why they are feeling bad and what can be done to help them get better. The PWP listens to people. Listening is often taken for granted, but actively focusing attention on someone else is one of the most difficult, yet sincere, tasks of this professional experience. The PWP does not judge: they respect the experiences of others and care about the change towards a better life. In practice, this means that after an initial assessment, the goal of the PWP is to help the patient better understand their problem and propose possible solutions.

Preventing relapse

The patient, in turn, will try to put into practice the new strategies learned in therapy. By providing the tools to allow the patient to become a therapist for themselves, the PWP aims to reduce the risk of relapse. Keeping the patient motivated and positively engaged during treatment sessions is crucial. Harter (1978) states that every individual who engages in learning tasks is largely influenced by the perception of competence. This perception will affect the outcome of the task following two possible directions: on the one hand, a tendency to want to feel more and more competent, and therefore to engage in the task and get busy; on the other, the fear of feeling incapable, which will lead to a growing demotivation and lower commitment. And this is where the real difficulties of the job usually arise: people, especially if emotionally vulnerable, often tend to distance themselves from the service as they do not believe they are 'good enough'. It is important to understand the expectations and clarify the reasons why it takes time to be able to regain control over thoughts, actions and self.

PWPs do make a difference to people's lives. If the development of mental processes is formed in social interaction, in a therapeutic context it is possible – even in a short time – to give rise to new cognitive and behavioural adaptations through daily practice (Bruner, 1990). Patients are experts in their problem; PWPs are experts in mental illness. Through the relationship, this knowledge can be exchanged in order to form an effective recovery plan. We don't have a magic wand, but we do have many other useful tools. This is the basis of a patient-centred approach, where the patient becomes an active protagonist on their own therapeutic path (Richards & Whyte, 2011). The PWP takes on the role of facilitator, leading to the achievement of a common goal: autonomy. 

I often find it helpful to point out to my patients that each of us has 'the right to be wrong'. Making mistakes is a learning resource towards a gradual restoration of mental wellbeing. Encouraging my patients to constantly test themselves is an important point for maintaining a non-judgmental climate in the therapeutic relationship, and for developing mutual trust within a few treatment sessions.

Understanding the job

The burn-out rate as a PWP is high. It is stressful to manage a very high caseload, which mostly happen over the telephone. Since the early days, I have always tried to look after myself and to prioritise my wellbeing. After all, being comfortable with yourself means being able to be comfortable with others. 

For this reason, I think that a greater awareness of the profession for all those who would like to apply to the role of PWP should be considered. Understand that what new applicants are going to do is not to be taken for granted. Many new to the role, carried along in the excitement and novelty of the new job, lack a full understanding of what a PWP faces. I've noticed that it is not easy to find detailed views of what the PWP actually does. Only recently a few articles and online videos have given more insight into the role – there is still a lot of work to be done to better spread information around what it really means to be part of this 'low-intensity' therapy taskforce. So I'll end with an appeal to those like me who are lucky enough to do this job: for better or for worse, we should make our voices heard.

- Sofia Airoldi is a trainee Psychological Wellbeing Practitioner within NHS Oxford Health.

References 

Beck, A. (1970). Cognitive therapy: Nature and relation to behavior therapy.  Behavior Therapy, 1, 184-200.

Bruner, J. (1990). Acts of Meaning. Cambridge, MA: Harvard University Press.

Ellis, A. (1962).  Reason and emotion in psychotherapy.  New York: Lyle Stuar.

Harter, S. (1978). Effectance motivation reconsidered: Toward a developmental model. Human Development, 21, 34-64. 

National Institute for Health and Clinical Excellence. (2011). Common mental health problems: identification and pathways to care (Clinical guideline 123). Retrieved from https://www.nice.org.uk/guidance/cg123

Papworth, M. & Marrinan, T. (2019). Low Intensity Cognitive Behaviour Therapy: A Practitioner's Guide (2nd ed.). London: Sage. 

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 (3rd ed.). London: Rethink. 

Westwood, S., Morison, L., Allt, J., et al. (2017). Predictors of emotional exhaustion, disengagement and burnout among Improving Access to Psychological Therapies practitioners. Journal of Mental Health, 26, 172-179.