How to Build an Island (2): The Jenga Solution

I’m excited about writing this one, we’re getting into the stuff that really floats my boat now, and the examples in this post are based on what’s happening in real life, not just wishful thinking. Triple integration of physical, social and mental healthcare is the future; that’s the hill I’ll die on.

But before I get into that I need to say this: I was talking to a Low Intensity Therapist (LIT) today who qualified six months ago. This person has always been energetic and optimistic when I have seen them before. They work in a well-run IAPT service that meets it’s targets and does a lot to support staff wellbeing. I noticed that the LIT was looking tired; they were slumped and tense around the mouth and eyes, I asked how they were doing. They told me that they’re struggling, that working full time is taking everything they’ve got and there is always more to do. They told me that it’s really hard not to keep taking more on because there’s so much that needs to be done. That’s after six months; it’s no wonder that two years is a lot of people’s limit. We’ve got to get better at looking after LITs (and everyone else who works in the NHS but that’s a lot bigger than my resources can sort out), we’ve got to recognise the cost of low intensity work and change the systems around it so that it becomes sustainable or we’ll hurt a lot of good people and lose this vital and exciting role.

[A LIT is] constantly hearing accounts of difficulty, constantly having to explain that they can’t help with the difficulty that is foremost in the patient’s mind, constantly dreading what they might have to manage on a clinical day while feeling under-equipped to do much about it. It’s wearing.

A couple of posts ago I wrote about the effect that powerlessness and helplessness can have on LITs, using myself as an example. Some of the distress in those situations comes from not being able to do anything to help; compounded by a perception that no one is doing anything to help. I’ve never met a LIT who is unaffected by suffering, or one who isn’t a natural problem solver (although maybe the job brings that out in us?). Our compassion leads us into the job and when the job doesn’t resource us to relieve the suffering that we encounter, we become sufferers.

The High Intensity solution?

I’ve got friends who were LITs and Senior PWPs who are now High Intensity (CBT/HI) therapists because of this helplessness. CBT training is a way to equip yourself with more tools. The High Intensity toolbox has got more interventions in it than the Low Intensity toolbox; HI also work with fewer people for longer so they are more likely to see change happen, and feel like they have been part of making it happen. My former LIT friends tell me that the HI working week is much easier than the LIT week, and they get paid more, obviously so it’s an attractive option. If you’re a High Intensity therapist you’re less helpless, you can do more… that’s the theory anyway. When I thought about this, I realised that this isn’t true; High Intensity therapists can do more to help people where the main source of difficulty is moderate-severe depression and anxiety, but they can’t necessarily do more than a LIT for many of the people who come to IAPT for help. My HI friends are just shielded, by the LITs, from the people who can’t be helped by IAPT services.  

This is in no way a bash at HI Therapists; Low Intensity work doesn’t function outside a stepped care system, you’ve got to have something to offer to the many people who need the more intensive therapy; without HI, LI can’t exist. The work they do is very challenging in different ways, for example I’m really not sure I’ve got the personal qualities you’d need to be able to do trauma focused work. As things are now HI is the natural career progression for low intensity therapists (wouldn’t it be great if that could be formalised so that we have some actual career progression?). I’ve known many HI therapists who respect, value and support their low intensity colleagues, and that’s more likely when they used to do low intensity work themselves.

integrated working would give us the chance to progress in treatment with people who do need what we can offer, instead of treading water (and sometimes drowning) with people who need something else

The people who LITs see often seek help for problems that are not depression or anxiety. Or their depression and anxiety are linked to any or all of the following: insecure and unsafe housing, benefits (poverty, insecurity, debt and stigma), social isolation, poor nutrition, unhelpful health behaviours, grief, Long Term health Conditions and Medically Unexplained Symptoms, racism and institutionalised discrimination, poor literacy and lower educational attainment, unemployment, cultural pressures, dysfunctional family dynamics, developmental trauma and local crime rates.

Patient A

Patient A is a real person who I met a few years ago, with enough detail changed to protect anonymity. They scored in the severe range on both the PHQ-9 and GAD-7. They were living in a council home with black mould on the walls; one of their children had got asthma and this person was constantly worried that the mould would affect the child’s health. Despite frequent efforts to get it sorted 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. This patient arrived in the UK as a refugee from war five years before we met and had only just been 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. Most of their family are in the country of origin and the patient knew that their close family are in danger on a daily basis. 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 ask 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. 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 explains that in their language 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 wont prescribe this medication but did refer them to a physiotherapist. The patient says that physio doesn’t help and asked me for pain medication and an MRI scan. They also asked me to get someone to remove the mould from their house and write a letter to the Jobcentre.  

This patient didn’t progress in IAPT at that time.

Low Intensity

When we meet people with so many challenges a LIT might tap the bricks (I’ll explain this more in a couple of paragraphs) by attempting to explain an ABC or 5 areas. The LIT might attempt to explain problem solving, worry management or Behavioural Activation. If they’ve done the LTC top up training they might try to explain pacing and the importance of doing some movement regularly to manage pain. The people in very demanding situations who we see often focus on their external circumstances (very sensibly) and wont come back for more than one or two appointments after assessment when we can’t offer anything more practical than signposting. Sometimes it’s the right time for things to progress in IAPT. Sometimes, if the rapport is good, they might come back for a chat until the PWP has to refuse to offer more supportive listening appointments.

It’s the idea that a person is a whole person – they aren’t just their physical health, they aren’t just their social circumstances, they aren’t just their mental health, they aren’t just whatever has happened in the past; they are a whole and complex person and they can have choices about where and how they step onto the circle of care.

High Intensity

So, doing HI training is a way to way to offer something different, something that might feel more effective than low intensity, it’s one way of finding some footing in the flood. It’s also a way to influence the system; HI therapists are in a leadership role and often have the opportunity to review notes and see a LIT assessment before they offer a first appointment. They might recommend another service or just decline to see someone who seems unlikely to be in a position to engage with a more demanding talking therapy. Although they have got an expanded toolbox, they apply it to fewer people. Which isn’t bad, it’s unethical to attempt a course of treatment that hasn’t got a reasonable chance of success; which LITs sometimes forget amongst the pressures to do something.  

This system leaves the LIT in a tricky position – constantly hearing accounts of difficulty, constantly having to explain that they can’t help with the difficulty that is foremost in the patient’s mind, constantly dreading what they might have to manage on a clinical day while feeling under-equipped to do much about it. It’s wearing.

Jenga

Lets think about Patient A. Their list of problems looks something like this:

• Housing
• Query about children’s wellbeing
• Probable daily micro-aggressions 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. If you get the right brick, or bricks, to shift then the whole tower might collapse.

Think about being the LIT who has to figure out if there is a way into this interlocking pattern. Think about being the patient being poked with questions, and then told that the person you’ve disclosed all of this to wont see you again but wants you to go and see three or four other people first. Are you going to walk out of that appointment and pick up the phone to talk to yet another person, or are you going to walk out with the feeling that no one can help with anything and just go back to your GP whenever the pain gets too bad?

The LIT has got tools that might shift one or two of those bricks, a HI/CBT therapist might have tools that could affect one or two more. Both of those people work either in an isolated setting or in an office full of other IAPT people with the same competencies and resources that they’ve got. The chances of making a significant difference to this patient’s Jenga tower of distress are pretty small.

An alternative reality

Excerpt from the IAPT Manual (2019)

So, what’s integration got to do with this? Remember – that this bit is based on real life too, it’s happening, although I don’t know of anywhere that has managed to produce this exact nirvana yet:

Imagine that LIT or HI therapist in a different setting. Instead of an isolated room or an IAPT office they’re in a community wellbeing center. Lets take a tour of the building.

There a suite of modern medical/clinical rooms along one coridoor, 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
• 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
• There’s a discounted gym with health trainers and a swimming pool
• There’s a lovely café
• Citizen’s advice and employment and community support workers are available a couple of times a week
• Local third sector organisations who run horticultural therapy projects 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
• Support groups for several Long Term Health conditions meet there often
• Facilities include large rooms that are used to run classes that IAPT and physical health practitioners co-produce with patients to answer the most common questions and worries, and teach self – management skills for LTCs and long term pain
• This community centre is full of other people of the same age and mobility as the patient and it was purpose designed to feel relaxed and welcoming, while making movement feel safe and normal.

Possibly the most important factor is that all of the health and social agencies who work there share information and record keeping by default (clients can opt out of this), and GPs are kept in the loop. The LIT might quite naturally provide a bit of guidance and co-ordination through these linked services within a collaborative care model.

Suddenly there are many more options – lots more resources to tap the bricks with – and that one isolated IAPT worker doesn’t feel like they have to have all of the solutions. The patient who starts with IAPT sees the same interpreter every time they visit the centre. They don’t realise that when they talk to the citizens advice worker and the pain management consultant a couple of weeks after their IAPT assessment that they are seeing people from a different team, because it feels like one service.

This wouldn’t have to be how all IAPT treatment was offered, but if it was a portion of the LIT working week how brilliant would that be? One of the things that burns us out is the isolation and crushing responsibility for things that we can’t effect. What we do is good, when we get a chance to do it, and integrated working would give us the chance to progress in treatment with people who do need what we can offer, instead of treading water (and sometimes drowning) with people who need something else.

The Circle of Care

The bio-psycho-social model

The Bio-psycho-social model offers a good basis for understanding integrated working. It’s a venn diagram: three circles that represent physical health, psychological health and social health interlock, with the person in the middle. If something changes in one area there will be changes in the others. You could overlay a fourth circle on this diagram, I think of it as the circle of care: one unbroken line that encompasses the whole experience and surrounds the person in need with access to all of the sources of help that are locally available.

Is integrating IAPT with other services the solution to some of our LIT difficulties? Is Step 2 the right level to do this? I think so. The only real danger is drift, and that can be managed through supervision. Integrated working is something I get very excited about, you might be able to tell. It needs time and resources to set up (the Trust level negotiations alone can take two to three years and are not within the purview of the LIT) but it’s a brilliant concept. It’s the idea that a person is a whole person – they aren’t just their physical health, they aren’t just their social circumstances, they aren’t just their mental health, they aren’t just whatever has happened in the past; they are a whole and complex person and they should have choices about where and how they step onto the circle of care.