Opinions on the IAPT scheme?

This section is for discussion relating to the Layard report, and subsequent schemes like Improving Access to Psychological Therapies where lower intensity inteventions are offered in primary care
lisak2000
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Opinions on the IAPT scheme?

Post by lisak2000 » Fri Apr 06, 2012 7:03 pm

Hi guys,

I'm currently writing a paper on the IAPT scheme, and I thought it would be interesting to hear your views on it - in particular, if you currently work within this area. I've done some basic searches on the forum already, I just wondered what you all thought about the current state and future direction of the scheme, in particular any worries or criticisms you may have.

Thanks :D

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Re: Opinions on the IAPT scheme?

Post by Borrowed Cone » Fri Apr 06, 2012 7:40 pm

perhaps you could kick things off with your position on IAPT?
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Re: Opinions on the IAPT scheme?

Post by Will » Fri Apr 06, 2012 8:09 pm

lisak2000 wrote:Hi guys,

I'm currently writing a paper on the IAPT scheme, and I thought it would be interesting to hear your views on it - in particular, if you currently work within this area. I've done some basic searches on the forum already, I just wondered what you all thought about the current state and future direction of the scheme, in particular any worries or criticisms you may have.

Thanks :D
That's a very broad question! Perhaps it would be useful to ask more specific things, or provide an overview of your paper.
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Re: Opinions on the IAPT scheme?

Post by michael2806 » Sun Apr 08, 2012 11:26 am

Just to give a background, I previously worked as a low intensity therapist in IAPT for 2 years, specialising in CYP IAPT towards the end of my time there.

I think on balance IAPT could be a good development, as it ensures that individuals can access psychological services for mild-moderate issues, before classical mental health services would have seen them further down the line, usually when problems would have become more severe. In this sense it serves a preventative function of sorts. Also it ensures that people don't have to sit on waiting lists for too long, meaning quicker access to services as a result of more clinicians being available. I do stress that the points listed below are considerations drawn from personal experience and limited knowledge of the IAPT scheme, so may not be applicable to other services and may therefore be at odd's with others experiences.

The positives listed above come with a few significant considerations and draw backs:
- The lack of clinical supervision. In my experience, LIT's had to shoulder considerable caseloads with very little supervisory input outside of the 'case management' model of supervision.
- The high caseloads in themselves. The very fact that people are expected to have such high caseloads as LIT's is a bit worrying, and I think can have detrimental effects on the well-being of staff. I wonder how these frustrations may feed into unhelpful transference and counter-transference interactions in clinical settings, something made all the more challenging by the lack of clinical supervision.
- The constrained model of working. I saw many people who benefitted from the low intensity adaptation of CBT. However, I think it is a dangerous assumption to believe that CBT will work for everyone. There were a substantial number of people who, in retrospect, would have benefitted much more from another style of working. As such I wonder about the clinical and ethical ramifications of cramming individuals with such a diverse range of issues into one model of working.
- Individuals rarely present to services with 'mild' mental health issues. As such, I found most of the individuals I was working with tended to be dealing with problems more complex than my training had prepared me for. I believe that in our service, you would find people at step 2 would often work with step 3 issues, step 3 would see more complex clients as a result, and so on.
- The lack of available career progression and CPD for staff. LIT's are typically (though by no means universally) young, aspiring graduates who are hungry for knowledge, experience and, eventually, career progression. IAPT I believe has recently (though DO NOT quote me on this as I dont mean to spread unhelpful rumours!) spoken out about restricting LIT's from progressing into HIT posts. I think this is a catastrophically bad move. People are going to want to progress and develop, and to keep people in role by the stick and not the carrot is poor strategic planning. I know the LIT role typically has poor retention of staff, but employees will not react well to restraint; a problem compounded in my personal experience by the lack of available CPD for LIT's.

I obviously provided this information with a caveat, in that this is a limited perspective from a trainee CP who used to be a LIT, so it lacks the strategic and managerial perspectives, and is very much provided 'from the coal face'.

Hopefully this will be helpful, please feel free to PM me if you want any more information :)

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Re: Opinions on the IAPT scheme?

Post by lisak2000 » Sun Apr 08, 2012 11:15 pm

I know its a really broad question - guess in a sense it's meant to be. I've obviously come across IAPT, LIW and HIW before in a very loose context without really knowing much and I guess the paper I'm working on has opened my eyes a bit more to the general issues, and I was just wondering what other people's takes were on IAPT as a whole.

For example, I agree with a lot of what michael2806 said about the benefit of attempting to intervene early when (in theory) a client is presenting with minor mental health problems rather than waiting until the mental illness develops into such a debilitating condition that they need to be referred for more intense treatment. Also, its a good idea to try to get people back into work who have been on sickness benefits due to depression, yada yada yada.

I think the main issues I have got so far is the provision of CBT for all, rather than an investment in some other forms of therapy which may be beneficial. Obviously CBT is good but it doesn't work for everyone, and it isn't beneficial for all conditions. From the recent articles I've read, it also sounds like slightly more complex mental illnesses are going to start being referred to LIW, such as 'minor eating disorders' (didn't know these existed but hey ho!) - i guess I'm just a little bit concerned about the ability of LIW to actually help here and the clients receiving the level of support that they actually need. Also, again as mentioned by michael2806, is the lack of progression. From what I understand, to become a HIW, you need to have a core profession and there are loads of clinical psychologists and so on training to become HIW. I guess that leaves me wondering what the LIW are supposed to do to progress or where they can go, given that being a LIW is, in some cases, an alternative career to clinical psychology for many psychology graduates.

However, from not having much experience of actually dealing with LIW/HIW or actually 'seeing' IAPT up close, I was just wondering if any of you lovely more experienced people could shed some light on anything you think may be problematic, and criticisms you may have, or even if you think it's the best thing to come to psychology since Freud ;-)

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Re: Opinions on the IAPT scheme?

Post by miriam » Mon Apr 09, 2012 12:31 pm

There was a huge interview article in Aspire on this topic. Have you read that?
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Re: Opinions on the IAPT scheme?

Post by Will » Mon Apr 09, 2012 4:41 pm

I think overall IAPT has been really positive. It's involved a lot of work and it has not been plain sailing throughout, but when you compare things now to how things were before, it's hard to argue things aren't better. Ultimately we want people to be able to access help when they need it. IAPT has put talking therapies well and truly on the agenda and the increased availability of evidence based interventions can't be a bad thing. In addition to increased provision, I think that has the potential (long term) to reduce the stigma around mental health, with more people are accessing services for 'common' mental health problems (especially when you consider the mental health promotion often undertaken by PWPs). In a relatively short space of time, IAPT has made a significant impact in challenging the postcode lottery of psychological therapy availability by redesigning primary care mental health services, often from the ground up.

Just to expand on a few points others have raised -

Supervision - Whilst IAPT has brought about a lot of standardisation, I think this highlights the differences which unfortunately do still exist across areas. In many, staff are very well supported through supervision - IAPT recommend case management supervision to safeguard every person accessing services, but staff should also have access to clinical supervision which focuses more on CPD and clinical skill development. I would class supervision as an area for development - it is up to services to prioritise it to protect staff and service users. With PWPs running with such high caseloads, services really need to recognise the importance of good supervision.

CBT for everyone - Again, a really valid point. There has been a lot of talk about increasing availability of other therapies and I really hope this doesn't get forgotten as money becomes less available. However we do need to remember the value of CBT - it does have a good evidence base and it can be applied to many problems. Additionally, as an obviously biased PWP, I think this highlights the value of our role. We don't offer CBT - we bring in things like sleep hygiene, medication advice, relaxation etc - things that many people will find really useful as standalone interventions (even if CBT isn't appropriate - more complex interventions aren't always better!). We can also incorporate the CBT based approaches such as behavioural activation, cognitive restructuring, exposure etc. I think it's also important to state that problems are considered 'mild' in the context of being compared (in a clinical sense) to more long term conditions. People we might describe as having 'mild' depression are experiencing symptoms debilitating enough to discuss with a GP, and then engage in a psychological intervention. These are real people experiencing real problems - and in need of some help.

With regards to developing the role to focus on other problems - my reaction to that would be as long as there is an evidence base for the interventions and as long as staff are trained and supervised appropriately - why not? Someone with an eating disorder may well benefit from guided self help interventions - they can always be stepped up if they need something more indepth.

Also PWP career development is something that has been discussed at length on this site - I think my response to that is to question why it's IAPT's responsibility? For many, the PWP role will be considered a career in itself. It's an interesting and varied role, with plenty of opportunities for personal and professional development. If people want to apply the skills they develop to chasing other roles (e.g. management, clinical training, HIT) then that's for them to do individually - there's nothing stopping them! You don't hear of people complaining of the lack of a pathway within other jobs (e.g. support work). I think the main problem is PWP roles are often held by young, ambitious psychology graduates, who are looking for an alternative to the AP role in preparing them for applying for CP. The knee jerk reaction to prevent PWPs from applying for HIT without two years experience is, in my opinion, the wrong way to go about it. To encourage them to stay in the role, PWPs should be able to develop within the remit of the role - pursuing interests, training, having opportunity to do promotion and group work etc. - but I think it's important PWPs recognise the differences between the AP and PWP role and not 'expect' a clear career path up the payscale to be laid at their feet. And I say this as a PWP making no secret of my long term plans to pursue CP!
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lisak2000
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Re: Opinions on the IAPT scheme?

Post by lisak2000 » Tue Apr 10, 2012 1:08 pm

Miriam - yes, I just came across it. I've only just come across Aspire and worked out how to download it :oops:

Will - that's really interesting to hear the point of view of a PWP practitioner. As I said, I don't have much hands on experience, just the theory side and even that's very broad as it's part of an MSc! I guess I've always seen working as a LIW as a stand alone career, I haven't really thought of it in the context of experience to get on to the DClinPsy - guess I've always liked to be different *cough* weird *cough* :wink: in terms of the career though, would you personally continue working as a PWP if the DClinPsy didn't work out for some reason? Or is it literally just a stop gap for the experience?

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Re: Opinions on the IAPT scheme?

Post by LIWY » Tue Apr 10, 2012 5:58 pm

lisak2000 wrote:

I guess I've always seen working as a LIW as a stand alone career
I'm surprised to hear that because I am yet to come across a PWP who thinks it a sustainable long term career as the role exists in the majority of services today. I remember our lecturer taking a count of hands during the PG Cert as to who planned to stay as a PWP - the result was..zero hands...It is an exhausting job, high caseloads, masses of paperwork. It's as emotionally demanding as a high intensity role, particularly for face to face work, it involves travelling between locations, possibly mental health promotion work too - and probably no chance to raise higher than Band 5, maybe Band 6 if you're lucky enough to be in a service that has such roles. Meanwhile, trained high intensities are on Band 7 - why would a PWP not want to move to High? The only reason I can see is if one finds it hard to do a lot of lone working as the nature of the PWP job means that you probably spend more time with your team than you would as a CBT therapist.

If you do find some people in the course of your research who see a future for the role beyond something for a few years, it would be good to hear from them.

I think the fact that NHS jobs has qualified PWP roles advertised regularly, that temp positions are available continually via locum recruiters, that just today I saw a PWP Band 5 role advertised for a London Trust that stated experience would be accepted if an applicant did not have the PG Cert demonstrates that attrition continues at a fast rate because the job and/or recruitment is poorly conceived and not a very satisfying career in the majority of services.

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Re: Opinions on the IAPT scheme?

Post by fledgling » Tue Apr 10, 2012 9:48 pm

lisak2000 wrote: From what I understand, to become a HIW, you need to have a core profession and there are loads of clinical psychologists and so on training to become HIW. I guess that leaves me wondering what the LIW are supposed to do to progress or where they can go, given that being a LIW is, in some cases, an alternative career to clinical psychology for many psychology graduates.
I don't think the PWP role in itself can be seen as an alternative to being a CP, as they are quite far apart in terms of training level and remuneration. However, many (myself included) embarked on becoming a PWP thinking that on the one hand, it is excellent clinical experience for working towards CP, and on the other, if CP didn't work out, we would have a good plan B option underway by working up to Hi intensity training (or we might enjoy IAPT so much that we wouldn't want to pursue CP after all). This is true to an extent and it is still possible for PWPs to progress to Hi intensity training, or to progress into management roles via a senior PWP post. However, as many PWPs (whose training had been paid for at great cost) started leaving for Hi intensity training after only a year or so post-qualifying, it now seems they are being discouraged from applying to Hi intensity training, in order to retain the PWP workforce for longer (see this thread: viewtopic.php?f=27&t=12798).

This therefore makes IAPT less of an alternative career path to CP. In my opinion, it is very short sighted. PWPs want to move on to Hi intensity training because they are mostly bright graduates (psychology or otherwise), who will not be content to stay at band 5 long term in a very stressful role. Without options to progress internally, they will not just think 'oh well, I'll stay as a PWP'- they will naturally look to other options externally. Whereas, If they were encouraged to move up the ladder within IAPT, this might retain their skills and the money/time invested in them within the IAPT scheme. I think michael2806 hit the nail on the head with the 'stick not the carrot' comment. However, as services do often need more PWPs than Hi intentity staff, and Hi intensity staff tend to stay in post long-term (thus reducing the need to train more), progression on this route cannot be possible for that many PWPs...

So, what is the solution? (Not rhetorical, genuinely don't know... :wink: ). Someone needs to come up with an answer though, as I think the sustainability of the PWP role is one of the key issues that needs to address if the IAPT model is going to work long-term. There's a nice challenge for your paper, lisak2000!

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Re: Opinions on the IAPT scheme?

Post by heather86 » Wed Apr 11, 2012 2:20 pm

Just thinking out loud, perhaps allowing PWPs access to further training and supervision so they can specialise in working at step 2 in certain areas such as older adults, long term conditions etc would be a way forward for the PWP role. Also allowing access to appropropriate levels of pay for this knowledge and experience be it quicker progression up band 5 spine points or access to bands 6 or 7.

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Re: Opinions on the IAPT scheme?

Post by michael2806 » Thu Apr 12, 2012 11:12 am

I think what others have said is bang on, it can be a rewarding job, but I just don't think it provides the kind of CPD, universal support accross IAPT services (in the form of clinical supervision) and progression to justify itself as a potentially sustainable career. Let's face it, the job will largely attract bright, young, aspirational graduates (psychology or otherwise). I was the PWP representative on one of the IAPT courses accreditation process, and I was amazed at how when people discussed the major problem of retention in the IAPT role, very little was said in the way of promoting the aforementioned points. It was mainly about re-defining the person spec to attract individuals with lesser training and qualifications (I assume they thought this would translate into greater retention?) and cutting off potential progression to HIT jobs. In fact I remember one member of senior staff saying that PWP's shouldn't be encouraged to undertake CPD to broaden their skills, as this would mean them working outside of their 'remit' *bangs head on desk*

As Flora 84 said, not all PWP's can progress to HIT, due to the fact that lesser numbers of HIT's are needed relative to PWP's (see the pyramidal shape of the stepped care model for reference). I don't know the solution, and I would love to hear a considered, researched and viable one should any of you dormant Einstein's of psychology have one :wink: I think IAPT has a big problem with this, and in order for PWP roles and IAPT to survive in the longer term, it needs to fix it somehow

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Re: Opinions on the IAPT scheme?

Post by Spatch » Thu Apr 12, 2012 2:27 pm

Just thinking out loud, perhaps allowing PWPs access to further training and supervision so they can specialise in working at step 2 in certain areas such as older adults, long term conditions etc would be a way forward for the PWP role. Also allowing access to appropropriate levels of pay for this knowledge and experience be it quicker progression up band 5 spine points or access to bands 6 or 7.
We have to accept from an NHS organisational perspective, there is a huge economic pressure on not allowing people to climb up the bands or progress up the ranks. This isn't only for IAPT but for almost every discipline. In fact I suspect that if IAPT is succesful in the way it is envisaged, there will be moves to start a cheaper, even lesser trained variant (Low low intensity IAPT anyone?), and there are even some lower banded roles in existance at the moment.
So, what is the solution? (Not rhetorical, genuinely don't know... ). Someone needs to come up with an answer though, as I think the sustainability of the PWP role is one of the key issues that needs to address if the IAPT model is going to work long-term.
This is not the answer you are looking for, but the more cynical part of me would suggest that in recruiting PWPs they could start to deliberately target graduates that a) are obviously caring, b) have non psychology backgrounds c) ideally have fairly medicore or below average academic ability, which would preclude them making it onto a DClinPsy and d) don't have the resources to do any costly self funded training that would be an alternative escape ladder out of PWPing (like counselling or other psychotherapies). Sweeten the deal by giving them a more flashy title like "Primary care specialist" and Houston, we no longer have a problem*.

*This is clearly satirical, but I am probably not too suprised if they are thinking of this already.

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Re: Opinions on the IAPT scheme?

Post by michael2806 » Thu Apr 12, 2012 3:37 pm

I dread to say it Spatch, but aspects of your latter point were already being considered amongst senior IAPT staff several years ago, as a means of increasing retention within the PWP role. As said previously, the idea of recruiting individuals with lesser qualifications and by association, aspirations to progress, has already been suggested, and I imagine there are other similar ideas on the table. Personally I find the idea of even less training for individuals working with common mental health problems terrifying. Talk about a 'skin and bones' service model! :roll:

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Re: Opinions on the IAPT scheme?

Post by LIWY » Thu Apr 12, 2012 10:15 pm

Talk of aspirational PWPs also reminds me that I know some aspirational highs, people who went through on KSA - who, after a couple of years as HITS are again feeling stuck and are now applying or considering applying for clinical.

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