Surviving as a PCMHW / PWP / LIW

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Surviving as a PCMHW / PWP / LIW

Post by Will »

For an excellent overview of what it is like to work at the forefront of the IAPT movement, I recommend baa’s wiki article. I decided to write this to share some of my experiences as a PCMHW and pass on some things I’ve picked up along the way. It’s by no means comprehensive, just a few things I jotted down over the course of a few evenings, so feel free to critique or suggest additional points. I’ve tried to pitch it at people coming into the role so haven’t gone too deeply into anything, I’ve simply mentioned some of the main things that worried me early on.

I think a lot of PCMHWs/PWPs/LIWs start their training feeling inexperienced, under qualified and panic stricken. I know I did. Sitting waiting for my first patient was one of the scariest experiences of my life. So if you’ve just started in one of these roles, read on. If you haven’t, well read on anyway.

Without further ado, here are Will’s Top Ten Tips for Surviving as a PCMHW / LIW / PWP. (Snappy title eh?)

#1. Read the self help books that you’re dishing out.
It sounds obvious, but let’s be honest, it’s not something that takes priority. However it really is worth spending some time sitting and going through the more common ones. There’s the obvious ones (e.g. Mind Over Mood, the Overcoming series) but I’d also suggest absorbing some of the more simpler materials (e.g. things on the Centre for Clinical Interventions website). Not only will it make choosing and delivering guided self-help materials much easier but you’ll find yourself using words, phrases and anecdotes that you’ve picked up along the way. I like to use ridiculous examples when explaining a concept to someone; most of these are things I’ve adapted from case examples in self-help materials. Whilst you obviously need in-depth knowledge of the interventions you’re using, use of the people-friendly terminology in the self-help books will make you a much more approachable and effective therapist.

#2. Dealing with risk
There are plenty articles on here about risk so I won’t bang on too much about it. Yet, well do I remember the panic on everyone’s faces during the first teaching session on risk assessment. Well do I remember the first time I asked someone about suicide, only for them to give me an answer I didn’t want. So I think it’s worth covering. First tip? Don’t panic. Second tip? Yep, that’s right, don’t panic. Be understanding and empathic, but be confident. Third tip – remember your training. If you’re not sure on the risk assessment model you were taught, go over it again and again until it is second nature. The last thing you want if you’re in that situation is to be wondering if you’ve covered all the bases. Which nicely brings me to my next tip – cover all the bases! Remember that risk covers not only suicide but self harm, risk to others and neglect. A supervisor once gave me a good piece of advice which I shall pass on to you lovely people. Always do everything you can, so that if the worst happened you could stand up in court and be confident you did everything you should have. Assume nothing! Whilst important to cover your own backside in this day and age, by taking that mindset you’re also making sure the patient is as protected as possible. Which again leads nicely to my next point - manage the risk appropriately. If you’re not sure what to do, ring your manager, supervisor, colleague, whoever answers the phone first. I tend to ring the Crisis Team the minute I get concerned, then put them on the phone with the patient. Let them make the decision as to whether they will accept them – don’t assume they’re not suitable and make the decision yourself. One final tip? You guessed it – don’t panic!

#3. Managing your diary
So you have a caseload of 90 people, admin keep booking people in, John can only make it at 8.45am on a Monday morning and Mildred needs home visits. Tracey keeps ringing to cancel and Dorothy won’t show up but then will ring you the day after you’ve closed her case and ask for another appointment. Your voicemail has ten new messages and you keep missing calls off someone who won’t leave a name or number. Oh and you have that ‘relaxing’ holiday next week, that means double clinics for two weeks either side right? Organisation is key! As someone who is naturally very disorganised, it took me months to get the hang of it. But learn from my mistakes. Plan your diary. Plan every_little_thing. Give yourself a few minutes after each appointment to write your notes, rather than spending your entire admin time doing it. Use your precious admin time for, yes that’s right, admin. Stuff you can’t do anywhere but the office. For me, that’s things like letter writing and photocopying. Things like session plans, ringing people to arrange appointments and seeing GPs can be done when I have a spare five minutes or a DNA. It might mean you have to wait until you get home to update your Facebook and beat that high score on solitaire but it will make your life easier! And while we’re on the subject – plan in your travelling time and when you’re going for your lunch! Nothing will screw up your day (and your performance) more than arriving ten minutes late, breathless and stressed.

#4. Stick to your service’s model
Again, something I’m perhaps guilty of not doing. Find out what your managers expect from you. Ask how your colleagues work. If you’re given 20 minute sessions to do guided self-help follow ups and your manager is telling you that you have a target of 47,568 contacts for the month, don’t be tempted to squeeze brief therapy into it. It can’t be done. It’s tough, as we’re trained to deliver brief therapy and not self help. But that’s the model and that’s IAPT! If unsure, talk to your clinical supervisor or your manager. Every service is set up differently and different areas expect different things from their Step 2 workers. It’s all part of the fun.

#5. I don’t know what self-help book to give out!
So you followed Tip #1 but Jim is sat in front of you and you have no idea what you’re going to send him home with. There’s so much going on he could use ten different books. Well firstly, forget the rainforests and send him home with a couple of things to get him going – maybe something quite general that he can use for a range of problems (e.g. things from Mind Over Mood). Still, don’t overload poor Jim, he has a life to lead too. Keep it simple! Is his mood low? Send him away with some basic mood management stuff to get him started, but tell him you’ll be using other resources further down the line. What I tend to do is have my favourite worksheets copied so I can say here’s an introductory booklet on whatever, but use this worksheet alongside it. Another pro tip? Use the goals that you’ve (hopefully) discussed to guide you. What does Jim want? Is his crippling social anxiety what he wants to address right now or does he just want to improve his sleep? Final tip? If in doubt, let him decide. Jim, I’ve got this and this. Book #1 talks about this, Workbook #2 talks about this. What do you fancy starting with? Maybe he’ll pick the friendly looking one with the talking tortoise or maybe he’ll pick the textbook. But let him choose! There’s a good publication on the IAPT site about choosing self help materials if you want further suggestions.

#6. Minimum data set
So if you’re part of IAPT you have to do all those delicious questionnaires at every session. Yuck. But kick and scream all you want, it needs to be done. So my advice is to incorporate it wherever possible. It’s handy in the assessment to use the psychometrics to guide your questioning. “So Larry, you say that you’re finding it hard to control your worry…nearly every day? What kind of things do you find yourself worrying about?” For follow ups, I tend to do the questionnaires at the start of the session. “So, how’s it going Larry? Had a good week? Shall we see if that’s reflected on the questionnaires?” If you’re using a computer package, see if you can get a graph up to show the patient. Be ready with explanations of why scores might be going up or down! Some people prefer to do them at the end of a session but I always forget if I try that. If appropriate for the person, encourage them to do the mouse clicking. It’s generally quicker, saves you from reading out the same questions all day every day and makes them focus a bit more - especially useful if you have someone who deliberates over every single answer! With such people it’s often useful to remind them that the scores aren’t an exact science, they’re just an indicator, and for that reason it’s important to go with your first reaction.

#7. GP liaison
So they’ve no idea what your job is, they keep sending you people who need counselling or anger management, they assume your service has a two year waiting list and no matter how many times you tell them your name in the staff room, they still won’t take your call when you’re sat with someone in crisis. You did a great presentation for them just last week about the changes to your referral process but what’s this? Ah yes, thanks, despite everyone nodding and agreeing, nothing has changed. Guess I should have stayed in bed that morning. Some GPs are fantastic. Enthusiastic, knowledgeable, caring and receptive. Some are not. Unfortunately it’s part of your role and to be blunt, if GPs don’t refer to you then you have no patients. If you have no patients, when Mr Cameron wields his axe and jobs start being cut, you might just be the one who suffers. It can be hard work. It can be demoralising and it can require a lot of time and effort. But stick with it. Things I’ve found helpful include NICE! BIG! COLOURFUL! flowcharts that they can stick on their notice boards. It’s especially useful if these include how and when to refer to other services too (e.g. Crisis, Gateway, Edit, Counselling). To be fair to GPs, mental health services have changed an awful lot in recent years and continue to do so, it is confusing. So make it as easy as possible for them. If you do a presentation, take lots of handouts with everything included - referral criteria, exclusion criteria, how to refer, what your service does. Who is their named staff member for liaison? It works best if you do it in teams, maybe have a Step 2 and a Step 3 for each practice. Keep that contact up, get them to know your name and encourage them to ring you if they’re ever not sure about a referral. Admittedly I’ve not done this yet, but we’re being encouraged to give GPs a call occasionally just to say “Hi, remember Freda you referred back in July? Well just to let you know she’s now able to manage her panic attacks and is doing her shopping in Tesco again.” The GP might just remember you that bit more, he might appreciate your service that bit more, and he might just appreciate that for once, someone rang him and didn’t want something from him.

#8. Managing stress
So you’ve got a patient who is really bummed about his job. All he does is work his fingers to the bone in a high pressure job which is emotionally draining and physically exhausting. He goes home and ignores his wife and kids, throwing himself even more into his work. He’s burnt out and has had to go off work because he woke up one day and just couldn’t face going in. Sound familiar? Like a pretty typical case? What would you do with this fella? Chances are you’d talk about stress management, prioritising his workload, organising his time and perhaps most importantly you’d do some behavioural work to ensure that he filled his spare time with relaxing and pleasurable activities. So why then is it okay for you to rush home after a full day of clinic work, check your emails whilst eating your tea, read a few journals, read anxiety fuelled posts on ClinPsy’s forum, panic that you’re never going to get onto clinical, throw food into your rabbit’s cage, watch Coronation Street, spend some time writing about how to survive as a PCMHW, then sit down to spend a few hours on the essay for your uni course that’s due in a week? Yes it’s tough, yes it’s stressful. But although it’s a massive cliché, your wellbeing needs to come first. It’s a cliché you’d think nothing about trotting out for someone else, so follow your own advice!

#9. I have no idea what to say!
Whilst doing my training I recall furiously scribbling down phrases we watched our tutor using, panic stricken that we would need to say the same things. Whilst it’s good to have phrases and stories from elsewhere, remember you’re sat in a room with a person. A real life fully breathing person! Imagine you were sat in the other chair…wouldn’t you want to be spoken to like, well, a human being? Of course be professional, but be friendly. Relax. Be yourself and be natural. And if you really don’t know what to say? Two suggestions. Number one – say nothing. Sit in silence. It takes guts but can be very useful. Chances are they’ll break before you will and they’ll say something to get conversation moving. Number two? Throw it back! Perhaps an example would illustrate it better…

Jane – “It was really awful. Why did he ignore me?”
Will - *panics as he has no idea why*.
Will – “Well what do you think Jane? Why do you think he did that?”
Jane – “I don’t know…”
Will – “Well think about the model we’ve talked about. Has anything similar happened before?”
Jane – “Ummmm…”
Will – “Well imagine you were me. What would you say to you?”
Jane – “Well I guess I would wonder if there was a reason I hadn’t thought of. Maybe he didn’t even see me…” and so on and so forth.

Obviously a very simple example there, but don’t feel you have to give them all the answers. Very often we work with limited information about a situation, we can’t possibly always know what to say. And remember, the whole point is to train them to see these things for themselves.

And finally…
#10. Feel like you’re blagging it?
It’s easy to say and hard to believe, but trust me…we’ve all been there! After doing this job for over two years I still have days where I think I’m the greatest PCMHW who ever lived, immediately followed by days where I feel useless and as though I should go and stack shelves at Tesco (not that there is anything wrong with stacking shelves of course, it is a worthy and honourable profession). Your first few months sat in your clinic will be hard work. You’ll feel underskilled and out of your depth. But gradually, as you gain experience and progress through your training, your confidence will increase and your competencies will develop. You won’t even notice it happening, but it will. Learn to have faith in your instincts and trust your clinical judgement. As hard as it is to do, don’t take it personally when people don’t improve, drop out or call you horrible names. There are so many variables at play when considering a person’s recovery (or lack of). You only have influence over a small part of someone’s life. Whether they improve or they don’t is never going to be entirely your responsibility. All we can do is the best we can, within the limits placed upon us.

So there you have my top ten tips for surviving as a step two practitioner. Whatever your job title, wherever your service, hopefully there are things here that will ease a little of that anxiety. Working in this field can be hard and demoralising, it can take a lot out of you. However it is also a job that can give you back so much – the confidence you get from taking on a room full of GPs and winning, the smile you go home with when that one pain-in-the-arse client grudgingly admits that you might just have a point, and the excellent feeling that comes with helping a genuinely lovely person get their lives back on track. Can’t beat it! Enjoy.
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