In this blog, we interviewed research assistant Bridie MacDonald about her work in IAPT.
What is the difference between a psychological wellbeing practitioner (PWP) and a high intensity (HIT) CBT Therapist?
PWP and HIT CBT Therapist are both psychological therapists in NHS Improving Access to Psychological Therapy (IAPT) services. Most therapists in IAPT, like myself, start as a PWP and work up to being a CBT therapist. PWPs provide guided self-help, based on cognitive behavioural therapy (CBT) principles, also known as low intensity therapy. They work with people who have mild to moderate mental health difficulties, such as mild Generalised Anxiety Disorder (GAD), Depression or specific Phobias. They see clients for usually around 6 half-hour sessions to assist with using the self-help CBT materials and with problem-solving.
A high intensity therapist (HIT) provides CBT to people with moderate to severe mental health difficulties. Depending on NICE guidelines, individuals with some mental health disorders would go straight to seeing a HIT CBT therapist, and never see a PWP. This would include those with obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and social anxiety disorder. HIT is often the last step in primary care before referral to inpatient or secondary care services. Sessions last 1 hour and can go up to 20-25 sessions, if allowed by the service. HITs are more collaborative and explorative than low intensity therapists.
Why did you decide to become a PWP over other clinical roles (e.g., DClinPsy, Counselling psychology)?
I decided on this route for several reasons:
The IAPT service will pay for training for you to become a PWP or HIT, whereas many other routes (such as counselling psychology or psychodynamic) have to be privately funded. Whilst the NHS also funds the doctorate in clinical psychology (DClin), as noted below, places are far more limited.
PWP and HIT CBT training courses have more places available and there are lots of opportunities to enrol in training throughout the year. In contrast, the DClin programmes are highly competitive, and only have an intake once per year. Even assistant psychologist (AP) roles, which are a pre-requisite for getting on the DClin, often have hundreds of applicants.
3. Ability to progress faster / get on a career path
I originally wanted to start with the DClin, but many people spend between 5-10 years in AP roles, getting experience, and applying to get on that programme. The yearly disappointment can be tough. I thought the PWP sounded like a good experience and a career path on its own. I could make career progress and still go for the DClin later if I chose to.
4. I like the CBT approach
I wasn’t particularly interested in more explorative or abstract approaches of therapy. CBT appealed to me because its evidence-based and there is a concrete emphasis on what we can do to move forward. Every session has a specific reason, with an agenda to focus on, and a desired outcome for the end of the session/treatment. I prefer this to more open-ended approaches. This can be a criticism of CBT and for some people it’s less helpful, but for others it’s a real strength. People can see their progress as they learn. It works more with my way of thinking.
What training is required to become a PWP or HIT?
PWP training is one year full-time, where half the time is spent getting a postgraduate certificate (PG Cert) and the other half working with a service. There are two ways to apply: 1) apply to an IAPT service for the job of a trainee PWP on NHS jobs (https://www.jobs.nhs.uk/), or 2) apply for a training course within a university, and put 3 services as options that you would work for. For the second, if you get to the interview stage then you will have a joint interview with the university you applied to, along with one of your services of choice.
You have to work for 2 years as a qualified PWP before you can apply to become a HIT CBT Therapist. HIT CBT training takes around a year. They are fully funded, salaried positions: Band 4 as a trainee PWP, Band 5 when Qualified, Band 6 as Senior PWP, and Band 7 as HIT CBT Therapist.
What was your career path?
I studied Psychology (BSc) at University, and while I was there, I had a part-time job as a support worker once a week. I also volunteered weekly for a women’s charity, working with homeless and vulnerable women. After University I worked full time as a Mental Health Support Worker for a council for 6 months before getting a Trainee PWP position.
After that I took a very typical route for IAPT progression: PWP to Senior PWP to HIT CBT therapist, which took 4-5 years altogether. I also did some part-time Lecturing on the PWP course which is a nice job. I decided to move around and have worked in 3 services to try them out. Some people stay in the same service, but I felt that I learned a lot to see how the different services work. It helped with the career progression and to break up the steps in training (so that you aren’t always seen as a ‘trainee’, and don’t become the manager of close colleagues). Practically, I was also moving around outer London areas a fair bit so changing homes meant I had to move services.
Are there other options for PWPs?
Yes, some people go from PWP to the DClin. Some stay as a Senior PWP for their career. It’s a nice role where you have some days clinical work and other days are management based, so a good balance. Senior PWPs can become full-time or part-time lecturers on the PWP training programmes or go into management roles. For example, I know someone who is now head of several IAPT services who worked up from PWP and has no other clinical training.
As a HIT CBT Therapist, you have more options for clinical roles. You can stay in IAPT or work privately, work with secondary care services, or go into specialist services such as PTSD services. Other training opportunities can arise which the service may fund you for if you’ve been there for a while, such as Couples Therapy work, Eye Movement Desensitisation and Reprocessing (EMDR) therapy, or interpersonal therapy.
What is it like working as a PWP or HIT in IAPT?
There are pros and cons, as with anything. You have so many patients and the complexity is often higher than it’s meant to be. People can burn out, and job turnover is often high. However, doing things like being a Senior PWP, lecturing, or working part-time in another job (e.g., administration, private practice, etc) makes it a lot more manageable.
It’s hard work, but you learn a lot and you get so much great clinical experience in a very short amount of time. Before the PWP role it took years for people to be able to have much clinical, therapeutic contact with clients. Your therapeutic and diagnostic assessment skills are great. Most PWPs do between 10-20 assessments a week, so you get good at them. You also move up quickly. As a Senior PWP, you get managerial skills just 2 years after your training.
It also varies between services, so you may like working in some and not in others. I worked in a service where all treatment was individual, and we basically had no waiting list. I worked in another where it was nearly all groups. The one I’m working in now is a mix of both, but unfortunately our waiting list is very long. It can be a bit of a lottery.
What does your typical day as a HIT look like?
I typically do 1 assessment a week now. As a PWP I used to do 15-20 assessments per week (as it’s one of the PWPs main roles). Assessments are the first contact with a client where we take an hour (or more) to explore what’s happening, do questionnaires, risk assessment, and work out what’s the best treatment option. My other sessions will all be hour-long HIT treatment sessions. As soon as I finish with a patient, I’m allocated another one. We have long waitlists so there’s never a spot empty. I manage my own diary though so can decide how the sessions are spaced out and give myself time to do admin in between. Once a week, I run an evening group which is a 10-week course on ‘Overcoming low self-esteem’ using CBT and Compassion Focused Therapy (CFT) techniques. This was my choice as I like running groups and low-self-esteem is an area I am very interested in. I funded my own training in CFT. I’m also a supervisor, so give weekly Supervision to a few PWP’s. Finally, I’m the lead for computerised CBT at my service, which means I help out if there are any changes or if new therapists need training. The further along you get in IAPT the more you can specialise and spend more time working in the areas you are interested in.
What made you decide to come into research?
I’ve always been really interested in research and after university I was applying to AP and research assistant jobs. I just happened to get the PWP role first, but I always felt like I would like to give research a go at some point. I also wanted a break from clinical work 5 days a week. Being a HIT CBT Therapist is not much easier than being a PWP, particularly while working remotely during the pandemic with very distressed people. Most of my colleagues are part-time, which seems to be actively encouraged. It’s nice to switch it up and have something completely different in the other days. I feel better for it, and I also feel like a better therapist and more able to focus in the 2.5 days of work in IAPT.
How are you finding the split research/clinical role?
I’m enjoying it, even if it was a bit of an ego check at first. I have gone from being relatively experienced, as a supervisor and head of several areas in the NHS, to feeling like I don’t know what I am doing half the time! But I’m seeing it as a good thing and an opportunity to widen my skills/knowledge. It made me enjoy my clinical role a lot more as I have fewer patients, so I can focus on them more. I have found that both jobs complement each other which is nice. Within the research role, I really appreciate the little things, like attending the weekly department seminar on a Thursday. It’s amazing that as part of this job you have such opportunities to learn and think. I enjoy learning about research, and from all my amazing colleagues. I thought I needed to be organised in my clinical role, but there is a whole new level of organisation needed in this environment. Attention to detail is something I will need to work on this year. Small details are not something people have much time for in the NHS, so it’s been good to remind me of areas where I’ve gotten a little lazy or out of practice.
I’m also finding that there are lots of different tasks and stages to running a research study, and you have to be adaptable. When I started, I was writing policy documents and terms and conditions, then learnt one survey delivery programme before we ended up switching to another! I am so impressed by all the other RA’s and other research colleagues’ ability to do this every day. There is a great, collaborative environment within the EDIT lab. Everyone has the opportunity to learn from each other’s strengths and colleagues make the time to help you out if you need support even when they are super busy themselves.
How can you prepare to apply for the PWP training?
You do need some clinical experience to prepare you. As PWPs offer lots of telephone treatment, volunteering for a mental health hotline such as Samaritans is a great experience to prepare you for calling people. Other roles such being a Support Worker or a Carer can be a good start. I would say, when you’re an undergraduate, get whatever experience you can. I was a support worker for people with physical disabilities to start with and later that led to being able to get a Support Worker role in mental health. It’s possible that research could prepare you as well if you worked closely with service users or patients. It depends a lot on what you gained from the experience you have and how you can explain that in your application. PWP trainees come from many different backgrounds and at all different ages/career stages, so there’s not one path to the training.
People who get into the interview stage tend to be those who use the language of IAPT and demonstrate a knowledge of how the service and treatment works (e.g., behavioural activation). IAPT manuals can be useful for interview prep and knowing buzzwords/phrases like “stepped care model”, “evidence-based treatments”, “NICE guidelines” (and what these mean) will help. Just make sure you do your research basically!