A Week in the Life of an IAPT Low Intensity Worker

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A Week in the Life of an IAPT Low Intensity Worker

Post by baa »

A week in the life of a trainee Low Intensity Worker/Psychological Wellbeing Practitioner by baa
I work part time at the moment: one day at uni and four days out in practice. My team has been established for approx 2 years, so we're over most of the teething problems, however, we're expanding up to three LIWs and three HIWs. Yes, we are taking over the world. I've worked here since Aug 2008. It's a very rural area, I cover 3 GP surgeries, two in one town and one out in the middle of nowhere.

Monday is uni day, so I arrive early to attempt to find a car parking space and to fill up on coffee before teaching starts. There are at least two NHS Trust represented in my uni group, plus extra people from Mind and employment support charities. Today we cover Employment and Occupation. Have a bit of a vague lecture on reasons to work vs reasons not to work. I decide that I need to trade in The Bf for a richer model. Discuss how each NHS Trust's IAPT team views the LIW role in getting people back to work - my view of my role in this is to address any issues related to anxiety and/or depression that is impacting on the person's work life, however, if there are issues relating to relationships with managers/colleagues, issues around disputes and disciplinaries, or the need for general career advice - I tend to refer my people on to the employment support charity - who are much, much better at this sort of thing than me!

The teaching session then collapses into the usual chaos of various people discussing the difficulties with IAPT in their area - this often happens, more so with the very new services.

Lunch and a good gossip with people from my Trust and the other Trusts, always good to hear what everyone else is up to. This can be one of the best things about the training course given the isolation you can experience in the LIW role.

Afternoon - a quick run through of our looming assessment. It's going to be a group activity: each person presents a person they have seen who has "some kind of diversity", then we all decide to focus on one in more detail and discuss the impact of that "kind of diversity" on the assessment and treatment plan. We discuss three people who have physical health issues alongside and sometimes related to the mental health issue, one Portuguese person, and mine: a clergyman with anxiety. We decide to focus on mine and decide on some topics to cover in the assessment next week. We also get an outline of the reflective essay we will have to write on our discussion.

Off to work. I start off planning to see a young man in one of the bases, he can't make my usual slot at her GP surgery as he's at college. Unfortunately he misses the bus (one an hour, my patch is rather rural), so I need to call him to rearrange. I was going to focus on social phobia with him, mostly cognitive restructuring alongisde some exposure work. He may well be stepped up once I've had my six sessions with him as he has a history of mental health difficulties as well as difficult family dynamics, but we'll see how he goes.

Drive to the other base to see a young lady at midday (again, she can't make my usual GP slot due to work commitments). More social phobia, so we focus on exposure and set some tasks for her to try out over the next two weeks.

After lunch, I badger the clinical psychologist for info on intrusive thoughts, I want a list of them to show people in sessions to help them to normalise their own intrusive thoughts. I run through the list myself and workout that I experience the majority of them. Oops. Tweak a few thought diaries for different clients, photocopy a million self-help guides.

Regular Tuesday afternoon at one of my GP surgeries, usual routine, turn up, forget yet another door code, find a spare GP room to borrow, and remove all medical objects from the desk. Two new assessments: One lady I'm quite worried about in terms of risk to self as there's a lot going on for her in terms of her family situation. So I let her know that I will discuss this with my supervisor and will contact her after supervision to discuss her seeing me or the high intensity worker. Second assessment: nice vague assessment letter about anxiety and depression. The lady is doing very well on antidepressants, can challenge her own negative thoughts, can use distraction well. So I suggest Overcoming Insomnia and Sleep Problems and discharge her. Have a DNA for my final appointment (social phobia, was going to discuss exposure work), so I write up some info on intrusive thoughts while I'm waiting.

Regular Wednesday morning clinic at the GP surgery in the middle of nowhere, first person previously experienced health anxiety, but is feeling much better, is knowledgeable about their own triggers, and has a good number of coping strategies. Doesn't want more appointments, so I discharge her. Second person attends for second session and we focus on testing the reality of thoughts related to GAD. Have had to make sure that they understand that my role involves looking at the anxiety rather than the difficult relationship with her parents, I let her know I could refer on to Relate if they feel it would help. Third person DNAs - this was the woman I needed to research intrusive thoughts for. Shame she's not here as I have actually planned the session! Have jinxed myself.

Afternoon - admin time at the moment, it's all about DNA letters and discharge letters. I also need to play phone tag with the counselling service to organise two referrals for people I have assessed but would benefit more from a counsellor than from a LIW. Telephone a bunch of people, if I don't get through then I send out opt-in letters. I have too many people on my caseload to send out appointments to everyone, especially as a good chunk will DNA the first appt and will never make contact. Just started the opt in system, hoping it will reduce the DNA rate!
4pm is supervision, so we run through my supervisor alerts on our record system, then run through my new referrals (five for this week), we sift out the ones that need a HIW, and discuss the focus of the assessment for the others. Then I discuss any people who I have concerns with/need help with. The lady I was worried about from Tuesday will be stepped up to a HIW.

First thing I call the lady from Tuesday back to discuss stepping him up to HIW, then it's more admin time - Send out a bunch of first appointment letters, attempting to stick within our 10 day target - managing it with one surgery, but failing miserably with the other two.
Get an email from my supervisor - apparently one of my GP surgeries has been singing my praises. Lovely to hear this, especially as they were a more reluctant surgery at the outset! There will be more referrals coming my way apparently!

12:30 IAPT team meeting.
I discuss running some workshops on anxiety and depression, I went to a Living Life to the Full training course and the outline for the workshops sound promising! We're hoping to start them off in the two towns that we cover. Pretty much all of the other LIW/HIWs are interested in running the workshops.

I also discuss referrals to LIWs of people with some symptoms of body dysmorphic disorder, I'm happy to take these people, but only if I get some training and actually know what I'm doing! It's aggreed that these referrals are suitable for a LIW and my supervisor gives me a whole lot of reading and asks me to prepare an overview of the CBT model of BDD for our next supervision session.

Then I have an overspill clinic from one of my busier surgeries, I've based it in the secondary care services building for the time being, but will be moving these appointments to a community centre. Three clients, all new, one with a stress related problem who DNAs, one man with mild OCD who has been stepped down from Secondary Care (he has bipolar depression, but that is under control via the psychiatrist), I do a basic assessment of his OCD and provide him with a self-help guide on OCD. I highlight the parts we will be focusing on in the session and ask him to read through them. The third person appears to have a mix of GAD and panic. They were seen by the psychology dept in secondary care, but has been stepped down to IAPT.

Regular morning clinic at my third GP surgery. I have two new assessments, and the newest HIW is shadowing me. I quite like having people shadowing me, as I have someone to talk to during DNAs!
The first is a young man who has been through most of the services in the area! From the psychosis early intervention, to drug and alcohol, to a government run employment training course and finally back to me. The employment course has worked it's magic, so I discharge him.
The second is a woman with panic disorder with agoraphobia since a bereavement some years ago, plus some possible symptoms of OCD. Definitely, definitely needs stepping up as too complex for six sessions of guided self-help.

Last of my Friday afternoon clinics (had to move the day due to an increase of referrals from the GP, he's sending more people to us than the counsellors now, it's good to know he thinks we're useful!). I see two people, one new assesment and one followup.
Finally dash back to base to see one more person at 4pm (bad timing on a Friday!). Supporting a person to reduce their hairpulling.

I wrote this a while ago, but never got around to posting it! I've now qualified and am working full time. I now have 5 surgeries, I cover four on my own and share the other with another LIW.

Other roles may be slightly different, depending upon the setup of the service.

A different perspective by kelebek
My experience is quite different as my service is fairly new. I do not have any GP's and I don't get to see clients at all. All our work is done over the phone. We wont be having any face to face work in this service.

I am not doing uni as I was upgraded to band 5, qualified position soon after I started as band 4. Although, I have started to question this decision as it seems like a ''money saving project'' for my service. But I am going to push them for top up training as it gets accrecited now.

I contact up to 15 patients every day. I usually get hold of 5 to 6 of them. go thorugh an assessment with them, it usually involves risk assessment. The patient and I decide suitable treatment for them, usually guided self helo cCBT or groupd work. I then type a letter to send them with our decisions about treatment.

I am going to run depression and anxiety groups very soon, that will give some face to face patient contact.

We have a reflective group meetings every week where we off load all our isues as a team. I have not received any supervison yet despite asking my manager every single day. I have been working without supervision for 2 months. But I got a promise today I am starting to receive supervision from this thursday onwards.

Example assessment protocol by Will
I was taught to follow the following protocol in an assessment. I'm writing this from memory (and it's 5pm) so apologies if I miss anything.

Introduce self
Elicit patient's preferred name
Explain job role
Explain purpose of session and set agenda / time scale
Discuss confidentiality and note taking.

Gather info
Use 4 W's to structure questions:
What is the problem?
Where does the problem occur?
With whom is the problem better or worse?
When does the problem happen?

Gather information on autonomic, behavioural and cognitive aspects of the problem. Enquire about triggers and environmental factors.

Discuss impact on personal, social and occupational functioning.

Brief history
How long been a problem, previous help.

Risk assessment
Thoughts? How intense?
Plans in place?
Vulnerability? Protective factors?
Respond appropriately.

Feed back problem statement.
Produce formulation and relate to model.

Goal setting
What does patient want from therapy?

Review problem, discuss plan of care.

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Last modified on 24/11/2010 by h2eau
Last edited by baa on Wed Jul 28, 2010 1:00 pm, edited 1 time in total.
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Post by LIWY »

It really does need to be added that many many services do not give PWPs the opportunity to be out in GP surgeries as much as Baa, many are phone only or even those that aren't still don't give so much trust or autonomy to PWPs.
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Post by h2eau »

There is a thread here split off from this wiki that discusses precisely this. The wiki will be updated shortly to reflect role developments and differences.
We deem those happy who from experience of life have learnt to bear its ills without being overcome by them ~ C.G. Jung
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Re: A Week in the Life of an IAPT Low Intensity Worker

Post by Punkgirluk »

I thought I would post a slightly more updated version (feel free to move to a new topic if that would be more helpful)

A Week in the Life of a PWP

Arrive at work at 8.15 (I don't start until 9 but parking is a nightmare....). First appointment is not until 10 so I use the time to catch up on some admin- discharge letters, a couple of phone calls to return from people needing to rearrange appointments and as always my inbox is full.
Today I am seeing patients face-to-face in our main office. We've only just relocated here so at the moment my caseload in this location is fairly manageable.
10am- first treatment session. A lady with GAD who I am thinking may need stepping up for HI work as she is still struggling despite engaging really well. Today we spend time talking about intolerance of uncertainty and how this maintains the anxiety cycle.
1030- second treatment session. A lady with social anxiety who has done really well. We schedule one more session to look at relapse prevention and then she will be discharged.
11am- Assessment of a new patient. Fairly straightforward- he is an older gentleman in whom retirement seems to have triggered an episode of low mood. I think he will find a few sessions of Behavioural Activation very helpful.
12 and 1230- 2 more treatment sessions. One with a lady just starting out on BA and another with a young guy who was struggling with panic disorder but who has exceeded both our expectations and feels completely better after just basic psychoeducation and a few controlled breathing and thought challenging strategies. Both of us are very happy as we agree he is ready to be discharged.
1300- Lunch! And a chance to see who else is in the office and have a bit of a catch up. Added bonus, my 1330 appointment has just rung to cancel as she has to attend an urgent meeting at her work. I will call her back later but for now I can have an extended break.
1400- Another assessment. This one is more complicated. There are definitely symptoms of PTSD but also some other things going on that make me wonder if it is actually complex PTSD in which case she may need to be referred on. There is also some risk to self. Happily...
1500 is supervision. I have 13 patients to discuss today- 9 new assessments and 4 reviews. My supervisor is an HI which is really useful as she can give a different viewpoint on cases I am a bit stuck with. 7 of the new patients are fairly straightforward but the other 2 need a bit longer. One is the patient I have just assessed and my supervisor and I go backwards and forwards for a bit. She isn't really suitable for trauma work in IAPT but we both know that she won't get access to step 4 psychology as she is still fairly functional. We will talk to our clinical team lead together, but probably will end up referring for an assessment in secondary care. 2 of my reviews are simple, and my supervisor quickly agrees that the lady from this morning is suitable for HI assessment. The other lady has social anxiety and has done pretty well but we seem to have got a bit stuck on one particular scenario she finds hard. I want to try a Behavioural Experiment to see if this helps and my supervisor agrees this is a good idea so we talk through how to adapt these to this particular situation. As always we have run over time so I rush quickly back next door for
1600 and 1630- 2 more treatment sessions. Another BA session and then some stress management to finish the day. Both of these patients are doing well and almost ready for discharge.


This morning I am co-facilitating a "Self-management of Depression and Anxiety" group session at a library in a small town to the East of our catchment area. It is session 3 of 5 so everyone knows each other by now and we're in a pretty good routine. My colleague and I share the presenting- we each have our own favourite bits! Today is predominantly focused on anxiety- so we talk through techniques for managing worry, panic and phobias.
Then I drive back to the office, collecting lunch on the way. This afternoon I am doing phone sessions (we offer all our patients a choice of format for treatment). My 1330 appointment DNA's which is frustrating, but means I will actually get time to eat the lunch I have bought. After a quick sandwich I fit in a bit of admin, calling the lady from yesterday to rearrange and finishing the discharge paperwork for the guy with panic.
1400- Another assessment. A lady with longstanding agoraphobia with panic. I suspect my goal will be to get her to a place where she can think about coming to face-to-face appointments. If we can get to that stage, she will probably need stepping up.
Another 4 treatment sessions follow from 1500 until 1700 (GAD, low mood x2 and a lady with quite severe OCD, with whom I am doing some preparatory work ready for her being stepped up) and then I spend another hour finishing off notes and attending to (more) e-mails.


Today is our monthly team meeting. There are about 30 of us in the team (about half and half HI therapists and PWPs) and we cover a large rural area, so this tends to be the only day we are all in one place! We start with a talk from someone from the local drug and alcohol service, which is fascinating and very relevant, although he does ask us not to refer people if we can avoid it as their funding has just been cut...Then we have our full meeting (apparently we're being rebranded as a previous name was thought to be putting people off. I bite my lip and refrain from asking how we would cope with any increase in referrals given we are already working over capacity), followed by our PWP meeting where we talk about the increase in people who are falling through the service gaps- who need more than time-limited guided self-help but who don't meet the threshold for secondary care. Our senior PWP will feed back our concerns to the clinical team lead and also to the seniors in other teams. In the afternoon we have clinical skills which is split into two parts. In the first half I am presenting an updated version of our CBT for insomnia group which I have been working on for a few weeks to reflect some of the more recent research. It seems to go down well, and there are a few helpful suggestions as how we could improve it further. I agree with the senior that I will make the final refinements and let him have a copy that he can share with the other teams. In the second half we split into 2 smaller groups and discuss any cases that present wider learning points, or that raise questions. I love these sessions as I feel I learn so much from them.


Another face to face clinic day, this time in a community hospital in another small town. I am also on duty today, which means I also need to find time to screen any written referrals (step downs from other services, or GP referrals where there is additional info we need to know, or where there are questions about suitability) and answer any queries that come in through the day. I like working in this location- aside from the luxury of a late(r) start (lots of parking!) and a stunning drive over the hills to get here, the staff at the hospital make me feel very welcome.
Start the day by looking at the duty referrals that have been scanned and e-mailed to me by our admin staff. There are 9 today, which is about average. A couple of them are straightforward and I put a note on their file and e-mail admin to ask if they will contact and offer a step 2 assessment. One is a straight not suitable as she made a serious suicide attempt less than 2 weeks ago. I make a note to feedback to the GP and explain why we are not a useful service for her at this point in time and under what circumstances that might change. On a bit of further decoding of another 2 (I'm not saying people write deliberately obtuse referral letters, but.....) it seems they are both people who have recently been seen by liaison psychiatry (which means we should have been sent a copy of that assessment and their recommendations- but as usual we haven't) so I need to chase up copies of those assessments before I can make a final decision. The other 4 I am unsure about and they will need to be called and the referral and their current circumstances discussed with them so we can decide together if our service will be helpful for them. I drop an e-mail to the HI on duty suggesting we split the calls and do 2 each.
And in the meantime, I start seeing patients. First is an assessment follow-up. This is a lady who is really struggling due to difficulties in her relationship with partner and stepchildren. We discuss what CBT is, and how this differs from counselling. She decides that counselling would be more helpful right now and so I talk her through the nightmare that is how to find counselling in our locality. I reassure her I will reiterate all of this in a letter...Then someone I have been doing cognitive restructuring for low mood with. He comes in and tells me he has been offered a job! This for him is massive as his low self-confidence and rumination had led to a vicious cycle of his being unable to apply for any work, so we are both very chuffed. We spend the rest of the session talking about maintaining progress and how to avoid slipping back into that cycle. His outcome scores say he is in recovery, but happily my service doesn't insist on immediate discharge, so we schedule a final (hopefully) appointment after about 2-3 weeks in his new job to check in with how he is getting on and any difficulties that have arisen.
My 1100 assessment is someone I immediately have concerns about. She attends with her partner who wants to sit in on the assessment. This would not be something I usually allow (unless for a specific reason such as memory or communication difficulties) but he doesn't take kindly to being asked politely to wait outside. For a moment I wonder if he is going to hit me, but then he seems to realise he is in the middle of an outpatient's department and several people are beginning to stare. Unsurprisingly, before we have even sat down, his partner is crying and I soon hear an all to familiar story of control and emotional abuse within the relationship. She can see she is desperately miserable in the relationship, but believes it is the best she deserves and is lucky he is sticking with her despite her being fat and ugly and stupid and.....(she is none of these things btw). I abandon the structured assessment (after checking for immediate risk beyond the obvious) and together we complete a referral to the local DV service. I reassure her no one will make her do anything she doesn't want to unless she is in imminent danger, and we work out a way that both I, and the DV service can communicate with her safely (which I put on the front page of her file so that anyone needing to can see it immediately).
Lunch time now, and after a quick leg stretch for some needed fresh air, I eat my sandwich while on hold to liaison for copies of the assessments I need. I also see that my HI duty colleague has replied saying she has a fairly quiet afternoon, so will make 3 of the calls required if I can do the other one. This will fit in nicely as I have booked off an hour in the afternoon (having learnt the hard way, and being thankful we completely control our own diaries) to finish up duty stuff.
1400 assessment is a lady who has generalised anxiety. This is one of the occasions when I really like my job because step 2 GAD work is probably one of the techniques that makes the biggest changes in how people are coping in a short time. I introduce the basics of CBT and give her our workbook to have a look at and we book another appointment for 10 days time.
Finish up the duty queries. I call the gentleman we were a bit unsure about and have a chat. He says that yes, he used to have a significant problem with self-medicating with alcohol, but that he has now been sober for a couple of years and wants to work on the low mood that has persisted even though he is no longer drinking. I follow this up with an e-mail to admin requesting they book him for an assessment. Make a couple of phone calls to referrers who want to discuss if someone is suitable. Liaison assessments still haven't been sent so I document this and let admin know to carry this over to tomorrow's duty.
Finish off the day with two more treatment sessions.


At a GP surgery today for more face-to-face appointments. 2 assessments and 9 treatment sessions. The first assessment is really interesting. It is a guy with a learning disability who comes with his support worker. I suspect we will need to talk about what adjustments we can put in place to make CBT helpful for him and I make a note to call the LD team to ask about easy read materials and anything that I can have a look at to prepare better for our appointments as I am not that familiar with working with people with learning disabilities. The other is a lady with health anxiety (which I must admit I always dread- for some reason I just don't feel comfortable working with people with health anxiety and I always feel like I don't know what I'm doing, no matter how much reading I do).
Amazingly the rest of the day goes smoothly (which for a Friday is unusual) and after another extra hour of admin I manage to leave at 6. The thing that would make the biggest difference to my working life would be some protected admin time- and I suggest it at every appraisal- but no luck as yet.......
As always, I am more than ready for the weekend!
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Re: A Week in the Life of an IAPT Low Intensity Worker

Post by lakeland »

Punkgirl this was such an interesting read - I felt exhausted thinking about how many people you have to see and how much you have to hold in your head about different people. Here's hoping you get some protected admin time - so important.
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