How to Build an Island (1): IAPT Low Intensity Supervision

In The Inescapable Torrent I started to talk about the ways that being a LIT in IAPT has changed me. A lot of that is down to powerlessness in the face of suffering, and utterly inadequate support systems that don’t acknowledge or address the reality of the work that we do. In that post I started to describe the rising tide that LITs are now neck deep in every day. In this post and the next, and hopefully more down the line, I want to talk about some of the ways that we keep some ground under our feet, and maybe even build a whole island to stand on. This has turned into a very long post, grab a coffee before you start reading!

This has been a difficult post to write. The blog after this is already written, it’s about integrating healthcare services, that one flew out. But supervision feels like such a big and important subject, and I don’t feel adequate to address it properly (the whole not a guru thing isn’t false modesty, I really am making this up as I go along). This post rambles all over the place and touches on a few things that people have written whole books and research papers about. But you can’t talk about low intensity work and not talk about supervision, so I’m going to do my best and ask you to remember that this post will barely scratch the surface, and there will be as many arrangements and opinions around this as there are people who think about IAPT. As always please check out the links in this post, they’re usually worth a look.

When the role of the LIT was formalised with the development of IAPT in England a whole new model of supervision was bolted onto it. Supervision isn’t a new concept – the ideas that psycho-therapeutic work might affect the practitioners, and that things might happen in a therapeutic relationship that should be talked about with an expert third party are as old as talking therapy. It emphasises the importance and safety of transparency when you’re doing this kind of work. IAPT was built on an understanding that all of the work offered by practitioners working in it’s teams would offer only evidence based, NICE recommended intervenitons for depression and anxiety. The difficulty of maintaining this standard was recognised and supervision suggested as a way to monitor and ensure adherence to evidence based working. It’s the single most important factor in maintaining clinical governance and safe and ethical practice in a high volume environment.

Supervision also encompasses elements of mentoring, peer support, skills practice, risk management and leadership. If one lesson has been well – learned in IAPT it’s that you can’t skimp on supervision. So it’s a shame that in many ways we’re still fucking it up for LITs; supervision is the one element of our work that could potentially protect our wellbeing and safety as practitioners, and maintain our joy and satisfaction in our work. What we have isn’t enough to do this.

High Volume Supervision when the intensity isn’t low

High volume, low intensity; lets come back to my favourite phrase for a minute. You remember how I think that low intensity should be banished from the vocabulary of anyone who talks about what we do in IAPT? It gives a false impression. Psychological Wellbeing Practitioners/Low Intensity Therapists in IAPT work with a high volume of patients. There were a few months once when my weekly caseload report consistently had 70+ people on it, which I (slightly gleefully – I’m not proud of myself for that) had to explain the Community Mental Health Team who kept emailing me to ask why I couldn’t offer a few sessions to some of their less risky patients. The number of patients on my caseload (this means that I had responsibility for their care in IAPT) when I was a full time Band 5 LIT never fell below 50.

The fact that LITs can carry that kind of caseload is what makes it possible for IAPT to reach its centrally mandated access target (I’ll write a post about targets soon, it’ll all make sense then). The high volume is supposed to be balanced out by the low intensity of the interventions that we offer, and of the difficulties that we help people to manage. Of course the interventions that we can offer are low intensity – we’re competent to deliver 6ish manualised evidence based interventions, it’s a small tool kit – but the intensity of the difficulties and problems that we see is not low. The balance is off, and supervision could be on the scales, it should be giving back some of the things that the work takes from us. It isn’t doing that at the moment, and whole big systems would have to change to enable that to happen.

Types of Supervision

So our supervision was designed with the role as it was imagined in mind, not the reality of our daily practice. Every service has different arrangements, so I’ll talk as generally as I can, and my own experience is obviously going to inform this.

LITs get one hour a week of case management supervision. Case management supervision is when you sit – usually at a computer – and go through your caseload report. Because there are so many people on that report there is usually a computer system that will highlight cases where certain triggers have been met, so that these are prioritised for supervision that week. New patients, people who report suicidal ideation or risk, people who score in the severe range on the questionnaires, people who have had four low intensity appointments, people who have not been discussed in supervision for a certain number of weeks… they will all be highlighted.

Cases are somehow presented to the supervisor (I usually just read the notes from the screen, other people prefer their supervisees to give a verbal report of the case), there might be some discussion, the supervisor either agrees with the course of treatment or offers some suggestions, a plan is agreed, a record is made of the conversation, and you move on to the next case. An aside: supervising an experienced full-time LIT once, we managed to have supervision on 27 cases in an hour. You can imagine the depth of reflection that takes place in that type of case management.

LITs should also get two hours a month of group clinical skills supervision. This was the nod towards reflection and the restorative function of supervision in the guidance. You’ll note that we don’t get two hours of reflective time a month, we get skills development. Just to make doubly sure that we don’t get big headed or start to take ourselves too seriously this happens in a group setting. How these sessions go really comes down to the group members and the facilitator. It allows more time for in depth case discussion and provides a desperately needed time for LITs to spend time together. It doesn’t go far enough to manage vicarious traumatisation and practitioner burnout. Not nearly far enough.

NAG’s top tips for surviving IAPT supervision

1. It’s uncomfortable to have your work scrutinised, especially when this is happening in an open plan office with half of your team working around you. We all make mistakes (I found out about a really massive fubar yesterday) and weekly supervision means there’s no way to avoid confronting them. You have to live with the discomfort and just get on with it. Be honest with yourself – is your supervisor really a dick or do you just find being confronted with your own normality and lack of perfection deeply uncomfortable? Learn to embrace being challenged and the never-ending learning opportunities this work affords. A sense of humour will help a lot and I promise that in a couple of years the discomfort does fade.   
2. That being said: If you really don’t like your supervisor, can’t learn anything from talking to them, don’t feel comfortable being honest about your work with them, then say something. You should always have this conversation with the supervisor themselves first and try to work out what’s not working and try something different. If that doesn’t work then talk to your line manager or clinical lead about being allocated a different supervisor.
3. If your service can’t make adequate supervision arrangements for you then leave and work in a different service. There’s a national shortage of LITs, someone will want you.
4. Be self-aware. If you’re not self -aware don’t work in IAPT. Your supervisor is also a PWP with a massive caseload and too little time. If you’re struggling, if you’re affected by something that comes up in your clinical work or in supervision, your supervisor might not know. You need to know yourself and know when things aren’t OK. You need to tell someone if things aren’t OK. Burnout is a real risk in low intensity work, but it isn’t inevitable. Know yourself well enough to know when things aren’t OK, and tell someone.
5. Take time in supervision to celebrate your successes. Low intensity work can have amazing effects, you’ll see some really exciting and wonderful things happen. Take a moment to tell your supervisor about this and enjoy the moments when people get better and reach their goals.

Who are the supervisors?

This is fun. This part of the work is about becoming really expert in what you do, knowing it inside and out, making excellent and safe decisions for the care of your patients and making sense of the effect it has on you – you’d want people who really know what they’re talking about providing that support, right? So, in yet another reflection of the low esteem that LITs and low intensity therapies are held in, someone decided that all you have to do is a five day training course that familiarises you with the assessment structure on an accredited low intensity IAPT training course and you can supervise a LIT. There are supervision competencies that are worth a look too. It makes me cross. I’m actually grinding my teeth while I type.

Obviously in the early days in IAPT there were no experienced low intensity therapists, we had to make do with whoever had seniority in the teams and who had some free time. What happened with that is that you’d have CBT therapists supervising LITs and coaching them to “have a go” at a few bits and pieces of Step 3 work whenever it felt convenient or necessary to manage waiting lists or “check engagement”. (You also get eager and ambitious LITs who do a lot of home reading and want to incorporate the latest ideas into their work, a supervisor needs to know the role well enough to stop them.) Or a MH nurse, counsellor, OT, psychologist or Social Worker who’d ended up managing an IAPT team by some fluke of career progression who might highly value the core competencies of person centred engagement but have no idea about the specific LI interventions, so you’d drift into providing supportive listening sessions with a bit of psychoeducation.

This year, more than ten years after the IAPT programme rolled out, there are still people calling themselves Psychological Wellbeing Practitioners who have never completed the training course. They’ve been doing great work and helping a lot of people. What they offer probably looks very different to someone who has completed the training and been supervised by someone who also completed the training. So then you have to ask – from a patient safety and governance perspective – what does Psychological Wellbeing Practitioner mean? (I still want it officially replaced with Low Intensity Therapist) and why aren’t we all doing the same thing if we’ve got the same job title? Its – well, it’s a mess, but we’re getting there with the release of the IAPT Manual and better, more effective  networks between services.  

It’s looking more hopeful

There’s an increasing number of people who have at least practiced as LITs for a couple of years who now provide peer supervision. Senior and Lead PWPs are occurring more frequently too, and they should be more experienced and expert in low intensity, with a demonstrated commitment to supporting and building up the profession. Having received supervision from people with various levels of familiarity with my role I can say strongly that I was safer and more supported when my supervisor was someone with significant lived experience of the job and the patient groups that I worked with. That type of supervision acknowledged the challenges and difficulties of my working week, without making me feel like I was being weak or dramatic when I spoke about it being difficult. They recognised my expertise and skill, while still providing helpful learning opportunities within my chosen modality. In an experienced LIT supervisor I also have an advocate who can help me to negotiate support and adjustments when the work takes more out of me than I’ve got to give.

Lets do more of this. Supervision also provides an incentive for people to stay in the job a bit longer, it’s an additional qualification and invaluable experience to be a clinical supervisor. Providing supervision changes the pace of your week and gives you opportunities to think about your work from a different perspective, which is refreshing and protective. Obviously people who undertake this training and fill this more responsible role in their team ought to be recognised with an increase in pay. I’ve never heard of that happening, but it should. Just a thought.     

NAG’s top tips for being a LIT supervisor

1. Have at least two years in the role before you start supervising, including your training year. You really don’t get your head around the job properly until you’ve done it for at least that long.
2. In case management once you’ve either read the notes or heard the case presentation your first question should be to ask your supervisee – ‘OK, what do you think?’. Don’t jump in with your own plan straight away, hear from the person who has actually had contact with the patient. There is subjective stuff that they will have picked up that can’t be recorded in the notes.
3. But equally there are some things that you can’t skirt around; don’t give any leeway with risk and safeguarding and make sure you’re shit-hot on these subjects, it’s vitally important.
4. Don’t avoid the difficult conversations. If there’s something that your supervisee needs to do differently then book a private room and talk it through with them, this includes matters around clinical work and skills, note-keeping and professionalism and office culture.
5. Get to know your wider healthcare system, there might be resources like additional training for your or your supervisee that with help you both (for example my IAPT team work in a big Trust and the trust offers clinical supervision training that helps with reflective supervision and practitioner wellbeing much more than the IAPT course does), and this is probably not going to come from within IAPT.
6. Look out for opportunities for your supervisee to develop areas of special interest and contribute to service developments.
7. Recognise their skills and expertise, take time every so often to tell them what you’ve noticed them doing well.
8. Use formal reflective tools to think about your supervisory relationship, contract properly and let your supervisee tell you what they need from supervision. If you can’t provide this then look for other resources where your supervisee can find what they need.
9. Use supervision of supervision. If this doesn’t exist in your team then create it.
10. Know how to recognise burnout and vicarious traumatisation and what to do about it. Encourage awareness around your team. Don’t offer therapy to your supervisee but know where they can get help if they need it. Ask how they’re doing and listen to the answer.

Has potential, but room for improvement

I joined IAPT at the start of its third year of operation. My team has changed around me in that time. One of my earliest memories in IAPT is of a new counsellor joining the team. She hasn’t worked in IAPT before. We were in an open plan office and I was about to have supervision; there was nowhere else for any of us to go, she was going to hear every word of it. By then I had already learned that many of the counsellors who worked with us were appalled by IAPT and its ways of doing things. To cushion the embarrassment for her I invited the counsellor to listen to my supervision session so that she could become more familiar with a low intensity workload. She was startled but thanked me and agreed. As my supervisor sat down and we began to look through cases on the computer without any introduction to the supervision session, or even cursory nods in the direction of my wellbeing, I watched the counsellors face. I’ll let you imagine her expression.

Our supervision arrangements haven’t caught up with us yet; but we get regular time to pause, look at the week that has just rolled over us, have it normalised, get some support and encouragement and fresh ideas. It’s one of the best bits of staying in the PWP role; being a supervisor gives you a change of pace, a new perspective, time to see your team and opportunities to learn skills that will progress your career. What we have isn’t adequate to our need but it’s not awful. Watch this space, just like everything else about low intensity interventions supervision is maturing and it’s the best way to keep solid ground under your feet.