‘We are able to reach such an array of people through many different means’
Rewind to November 2020. We were still at the height of the pandemic and I was working on minimum wage as a support worker in an assisted living facility. I felt overworked and undervalued, unable to reach my full potential in this role. I’d been stuck in the same job for 18 months and I wasn’t enjoying it. I had a first class master’s degree in Clinical and Health Psychology but had found it incredibly difficult to secure one of those fiercely competitive assistant psychologist or research assistant posts. The typical route to becoming a Clinical Psychologist seemed a distant prospect. I felt I was losing myself.
I applied for jobs, contacted psychologists for volunteering opportunities, even emailed well-known psychologists for advice. Then I came across a job advert for Trainee Associate Psychological Practitioners (TAPPs) in Lancashire & South Cumbria. It looked like something I could see myself doing – working in a primary care network to support mental health prevention and promotion via assessment, formulation and intervention. I met all the essential and desirable criteria. I spent hours perfecting my application and on 11 January 2021, I began my first week of training as one of the first 50 TAPPs to be deployed in the NHS.
This role was introduced in line with the NHS Long-Term Plan, which sets out to create a greater understanding of mental health within primary care and to increase access to mental health support for children and adults. The aim of this role is to target individuals who are ‘pre-caseness’, meaning they are supported at their earliest presentation of need. It can be seen as a bridge between a GP appointment and a referral to longer-term counselling or therapy such as Mindsmatter. Several patients have attended sessions with a (T)APP whilst on the waiting list for longer-term support, and have then no longer needed this after completing the (T)APP interventions.
When training, my typical week consisted of three days in practice, one day working in the community and one day studying with the University of Central Lancashire (UCLan). Some weeks consisted of five full days at UCLan. Since graduating, I now work four days in practice and one day in the community.
Our training consisted of meeting a set of competencies to ensure we would qualify as a confident and capable practitioner, as well as clinical and academic reviews, reflective practices, journal clubs and competency records which came together to form a 10,000-word portfolio which was submitted at the end of the year. Alongside this we also had to submit different forms of evidence, such as posters we had created, meetings we had attended and proof of good clinical communication. It was hard work but to see it all come together meant it was all worth it.
We attended several lectures (mostly virtual due to the pandemic) with UCLan across the year, which supported us in our daily practice. For example, we completed teaching on different therapeutic interventions such as Cognitive Behavioural Therapy, Solution-Focused approaches and Motivational Interviewing, as well as lectures on risk, working with children & families, setting up groups and inclusivity and diversity. It was great to begin learning via university teaching again, although due to the lectures being online, it was difficult to stay concentrated and motivated, especially during the weeks where we would have lectures from 9-5 Monday-Friday. Nonetheless, I managed to keep up with the teachings and apply it to clinical practice alongside the support from my clinical supervisor.
Reaching an array of people
Whilst working in practice, a typical day consists of around 4-5 sessions plus time during the week for supervision, CPD/training, meetings and other events. We were also encouraged to connect with other TAPPs during our training to reduce loneliness due to being spread right across the county, and these relationships have continued on after graduating. This means we can also schedule time into our week to meet up with other APPs. This may just be for a catch-up, or it could be to discuss collaborating together on something such as a community event or conducting research. We have also been given the opportunity to mentor the second cohort of TAPPs as they navigate their way through a new role.
Our ‘community work’ days are incredibly varied. One week I could be on a stall at a college fair to promote positive mental health, and the next I could be delivering an anxiety workshop to residents of a women’s refuge. This is what makes the job so rewarding; we are able to reach such an array of people through many different means. We are involved in our community projects from start to finish, meaning we design and develop the contents of whatever it may be that we are presenting, carry out the work, and then gain feedback where possible. For example, myself and a colleague collaborated to put together the presentation for the women’s refuge, which included psychoeducation around anxiety/worry and the symptoms, how we get trapped in the cycle and then different coping techniques. These techniques included worry postponement, grounding/relaxation techniques, breathing exercises and mindfulness. We were even able to try some mindfulness within the session, which they all really enjoyed.
We have also been lucky enough to attend different training courses to support our continued professional development. These include a 4-day health coaching course, in-house DBT, CBT and SFT training, and a 2-day introduction to ACT course. These have been invaluable in enhancing our clinical practice and providing us with essential skills and knowledge. The great thing about the APP role is that we are not bound to certain therapeutic interventions; we are able to take techniques from across all different interventions based on patient needs. This means we are contributing to person-centred care as we are able to tailor sessions to exactly what best suits the patient. For example, two different patients may present with anxiety, but their symptoms, thoughts and behaviours may be totally different to each other. I may decide to work on breathing and relaxation techniques with one patient, whilst working on thought challenging and de-catastrophising with the other. Ultimately, the decision-making is shared and I work collaboratively with each patient to develop their goals, work through the techniques and evaluate their progress.
We evaluate patient progress using both quantitative psychometric tests and qualitative feedback. We administer four questionnaires in the first, final and follow-up sessions – the Brief Resilience Scale, the Warwick-Edinburgh Mental Wellbeing Scale, the Patient Health Questionnaire-9 and the Generalised Anxiety Disorder-7. We also use a Patient Experience Questionnaire to gain feedback from patients at their final session to see how helpful they found the sessions and if they would recommend it to others. There are some downsides to using such questionnaires, as it depends on the person’s mood on the day or circumstances over the past couple of weeks as to how they will fill them out, meaning it can sometimes look like they have worsened in their symptoms. Patients can also find them tedious or difficult to fill out, meaning they may fall victim to survey fatigue, making their results inaccurate. However, it does help myself and patients when they are able to see an improvement in their scores.
Day-to-day, I work as part of a health and wellbeing team in a hub within a health centre, meaning I have a great team of professionals around me who are all supportive and knowledgeable. This has proved very beneficial for me in terms of both my own mental health and my ability to support others. I am able to turn to people for advice or reassurance and can also bring my own knowledge to the team to support the wider population. For example, I came across a difficult case during my training involving domestic violence and I was rather unsure as to what I should do. I was able to turn to the team co-ordinator and the co-ordinator support for advice. They were able to point me in the right direction and gave me all the contact details I would need. I was then able to deal with the case effectively and with caution.
Ups and downs
Now, it all sounds like a fairly smooth and easy journey from getting the job to become a qualified APP. However, there were many more ups and downs than I anticipated. Understandably, introducing a new role into primary care was met with several challenges, such as others not understanding the role and our remit, a lack of referrals, feeling isolated, and the dreaded imposter syndrome. These difficulties meant that a lot of my time was initially spent promoting the role and attempting to cultivate referrals. I did this by travelling around the practices in my primary care network, attending meetings, handing out flyers/posters, emailing clinicians and speaking to receptionists.
The lack of referrals meant I had spent little time actually practicing what I had been training for – carrying out assessments, developing formulations and working on interventions with patients. This led to imposter syndrome – a feeling of not being skilled or qualified enough to do my job and that people would soon realise this and wonder what I was even doing there! To overcome this, I made sure I spent enough time practicing self-care and being compassionate towards myself. I had to keep reminding myself that I was just a trainee and that I am not expected to be perfect or know everything. I was given a great tip by my supervisor, which was to write down all the positive comments and feedback I receive and then go back and read them when I am feeling unmotivated or incompetent.
Eventually, through a lot of promotion and using my initiative, my referrals began coming through and people were finally starting to understand the role of a TAPP. I therefore had more opportunities to practice and hone my skills in order to complete my training portfolio. By December 2021 I had officially passed the course and became a qualified APP!
I love that I am able to see patients within a couple of weeks rather than them being sent straight to other mental health services where the waiting lists can be over 27 weeks. I have received great feedback from both my colleagues and patients which really spurs me on to continue doing what I am doing. I have also been able to set up several groups to support local residents to gain confidence, meet new people and learn new skills.
Currently, there is great emphasis on diversity and inclusivity. Across the APPs, it has been noticed through data collection that there is a lack of engagement with patients from different ethnic backgrounds, with the vast majority of referrals being White British. This does not reflect the proportion of different ethnicities across several Lancashire PCNs, meaning more needs to be done to engage these populations. We are currently in the initial stages of figuring out how we can begin to do this. This is the main challenge at the moment and we are working hard to overcome it.
It’s safe to say I have learnt so much over the past 18 months – not only about the role, but about myself. I have grown in confidence, resilience and my general wellbeing has improved greatly. This role has propelled me into the world of psychology within the NHS and has opened so many doors for me and my career – I can only imagine where this role will take me!
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