Introduction
The wellbeing of the psychological therapy workforce is an important topic, with recent evidence to suggest that more than half of psychotherapists may be experiencing moderate to high levels of burnout (Simionato and Simpson, Reference Simionato and Simpson2018) and that psychological therapy practitioners experience lower levels of wellbeing than the general population (Summers et al., Reference Summers, Morris, Bhutani, Rao and Clarke2020). Increased levels of stress and burnout in this population have been found to impact negatively on a range of important outcomes including practitioner wellbeing, patient care, and ethical decision making (Delgadillo et al., Reference Delgadillo, Saxon and Barkham2018; Elman and Forrest, Reference Elman and Forrest2007; Pakenham and Stafford-Brown, Reference Pakenham and Stafford-Brown2012). A recent survey of UK psychological therapy practitioners also found evidence that lower workplace wellbeing was associated with a greater likelihood of wanting to leave the NHS, suggesting that workplace wellbeing may have an important relationship with high staff turnover in this population (Summers et al., Reference Summers, Morris, Bhutani, Rao and Clarke2020). Although research regarding trainee psychological therapists is comparatively scarce, existing evidence suggests that wellbeing may be further reduced during the training period, with trainees often reporting levels of stress and burnout that are greater than their qualified peers (Cushway, Reference Cushway1992; Cushway, Reference Cushway, Varma and Varma1997; Owen et al., Reference Owen, Crouch-Read, Smith and Fisher2021; Pakenham and Stafford-Brown, Reference Pakenham and Stafford-Brown2012).
In research to date, factors such as an excessive workload, hours of overtime, client characteristics and professional self-doubt have been associated with elevated levels of stress in psychological therapists (Hannigan et al., Reference Hannigan, Edwards and Burnard2004; Westwood et al., Reference Westwood, Morison, Allt and Holmes2017). Additional evidence suggests that for trainees, the competing demands of their academic workload, and the fact of holding dual roles as students and employees may exacerbate the stress experienced during this time (Owen et al., Reference Owen, Crouch-Read, Smith and Fisher2021; Pakenham and Stafford-Brown, Reference Pakenham and Stafford-Brown2012). Research into how psychological herapy practitioners and trainees cope with stress suggests that coping strategies such as talking to friends, using social support and exercise are common (Cushway, Reference Cushway1992; El-Ghoroury et al., Reference El-Ghoroury, Galper, Sawaqdeh and Bufka2012), with some limited evidence to suggest that high use of avoidance coping strategies such as denial may be associated with increased stress (Cushway and Tyler, Reference Cushway and Tyler1996; Walklet and Percy, Reference Walklet and Percy2014). In recent years, evidence has also accrued to suggest that resilience may be an important factor in withstanding the stresses associated with academic work and employment, with recent reviews highlighting the importance of resilience for the wellbeing and performance both of employees (Robertson et al., Reference Robertson, Cooper, Sarkar and Curran2015) and higher education students (Brewer et al., Reference Brewer, van Kessel, Sanderson, Naumann, Lane, Reubenson and Carter2019). Taken together, these findings suggest that research exploring the relationship between stress, resilience and coping in psychological therapy trainees may be important.
Existing evidence points towards the importance of early intervention in the prevention of burnout and the management of occupational stress (Maslach and Leiter, Reference Maslach and Leiter2016; Salvagioni et al., Reference Salvagioni, Melanda, Mesas, González, Gabani and de Andrade2017). As such, exploring the levels and perceived sources of stress at the outset of training may be an important first step, and may support the development of interventions designed to prevent the build-up of chronic work-related stress.
For more than a decade, the government’s Improving Access to Psychological Therapies (IAPT) programme has been radically transforming the provision of psychological healthcare in England. To date, several thousand therapists have been trained. This new workforce consists primarily of psychological wellbeing practitioners (PWPs), trained to use low-intensity CBT approaches to support people experiencing mild to moderate mental health problems, and high intensity therapists (HITs) who are trained to work clinically as cognitive behavioural psychotherapists. A recent systematic review found that research into stress and burnout in IAPT trainees is under-developed (Owen et al., Reference Owen, Crouch-Read, Smith and Fisher2021). To address this, further research using both quantitative and qualitative methods is required.
The purpose of this study therefore is to identify the levels and perceived causes of stress at the beginning of training in trainee PWPs. Further, it seeks to identify associations between stress and other examined variables including self-reported resilience and dispositional coping styles. A convergent parallel mixed-methods design was chosen for this study, meaning that quantitative and qualitative data were collected simultaneously from the same participants. Quantitative data were collected to identify levels of stress and relationships between key variables. Qualitative data were collected to explore the perceived sources of stress. These data were analysed separately, and then integrated to help provide a more comprehensive account of stress at this stage in PWP training.
The specific research questions that this study sought to answer were:
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(1) What are the levels of stress experienced by PWP trainees at the beginning of training?
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(2) What is the relationship between stress and resilience, and between stress and different forms of coping at the beginning of training?
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(3) What do trainees report to be the primary sources of stress at the beginning of training?
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(4) Can qualitative data regarding the perceived sources of stress be used to help better understand the levels of stress identified, and the relationships between stress and other key variables?
Method
Design
This study used a convergent parallel mixed-methods design (Creswell and Plano Clark, Reference Creswell and Plano Clark2011). This approach consists of collecting and analysing both quantitative and qualitative data during the same phase of research, in an attempt to use complementary data to arrive at a more comprehensive understanding of the research problem (Creswell and Plano Clark, Reference Creswell and Plano Clark2011). Descriptive statistics were produced for stress and resilience scores, and Kendall’s tau (τ) correlations were run to identify correlations between total stress scores and other measured variables (resilience and dispositional coping styles). Qualitative data were analysed using thematic analysis (TA) as described by Braun and Clarke (Reference Braun and Clarke2006).
Participants
Participants for this study (n = 90) were IAPT PWP trainees enrolled on two consecutive cohorts at the same English university, beginning in September 2020 and March 2021. Data from recent IAPT Workforce Census reports found that the IAPT workforce is predominantly female (82%), White British (81%) (NHS Benchmarking Network, 2022) and relatively young (approximately two-thirds being aged under 46) (NHS England and Health Education England, 2016). In order to fully protect the anonymity of participants (who were students on the course that the research team teach on), and thus to improve the quality of data gathered, no demographic information was collected about individual participating trainees. In total, 106 trainees were invited to participate, meaning a response rate of 84.91% was reached.
Participating university
The university at which participants were enrolled has a well-established PWP training programme that has been running for a number of years. The programme sits within a wider department that offers several different psychological therapy training programmes. Trainee PWPs at this university begin their training with a 5-day induction week, focused on the essentials of low-intensity cognitive behavioural therapy (LI-CBT) assessment. The training is closely mapped onto the PWP National Curriculum (3rd edition) (UCL, 2015a) and emphasises the development of LI-CBT clinical competency. In keeping with this emphasis, trainees take part in in-class role-play activities from day 2 of the training. From week 5, trainees begin to receive teaching on LI-CBT interventions, and Modules 1 and 2 subsequently proceed in parallel. Teaching in these modules builds towards a Module 1 and 2 Objective Structured Clinical Examination (OSCE) taken on the same day, approximately 4 months after the beginning of training.
Quantitative data
Perceived Stress Scale (PSS-10)
The PSS-10 is a widely used psychological instrument designed to measure the perception of stress over the last month (Cohen et al., Reference Cohen, Kamarck and Mermelstein1983). The scale consists of 10 questions which are answered using a 5-point Likert scale ranging from 0 (never) to 4 (very often). Total scores are obtained by reversing the four positively phrased questions and summing all items, with higher scores indicating higher perceived stress. The measure is designed to assess the general perception of stress and is not tailored to any specific situation. Examples of questions asked include: ‘In the last month, how often have you felt that you were unable to control the important things in your life?’ and ‘In the last month, how often have you felt that difficulties were piling up so high that you could not overcome them?’. The PSS-10 is a short and easy to use questionnaire that has been used widely in research on stress and wellbeing. It has well-established and acceptable psychometric properties (Lee, Reference Lee2012). Using Cronbach’s alpha, internal reliability in this study was α = 0.83.
Table 1. Descriptive statistics for Resilience and Dispositional coping styles, and correlations with total PSS-10 stress score
* Correlation is significant at the .05 level (2-tailed).
** Correlation is significant at the .01 level (2-tailed).
Connor-Davidson Resilience Scale (CD-RISC-25)
The Connor-Davidson Resilience Scale-25 is a 25-item measure of self-reported resilience. The scale has been used widely in research on resilience (Davidson, Reference Davidson2020) and has been shown to have good psychometric properties (Connor and Davidson, Reference Connor and Davidson2003). The items that make up the scale were drawn from previous theoretical and empirical work on hardiness, resilience and positive adjustment (Connor and Davidson, Reference Connor and Davidson2003). Example items include: ‘Having to cope with stress makes me stronger’ and ‘I am able to adapt when changes occur’. Items are answered using a 5-point Likert scale ranging from 0 (not true at all) to 4 (true nearly all the time). Answers are given based on the last month. Using Cronbach’s alpha, internal reliability in this study was α = 0.91.
Coping Orientation to Problems Experienced (the COPE Inventory)
The COPE is a 60-item multidimensional coping inventory designed to assess the ways in which people respond to stress (Carver et al., Reference Carver, Scheier and Weintraub1989). The 15 coping subscales and their Cronbach’s alpha in this study were Positive Reinterpretation and Growth (α = 0.79), Mental Disengagement (α = 0.57), Focus on and Venting of Emotions (α = 0.77), Use of Instrumental Social Support (α = 0.73), Active Coping (α = 0.70), Denial (α = 0.70), Religious Coping (α = 0.96), Humour (α = 0.93), Behavioural Disengagement (α = 0.65), Restraint (α = 0.75), Use of Emotional Social Support (α = 0.90), Substance use (α = 0.96), Acceptance (α = 0.69), Suppression of competing Activities (α = 0.50) and Planning (α = 0.79). The measure asks what people usually do when under stress and items are answered on a scale ranging from 1 (I usually don’t do this at all) to 4 (I usually do this a lot). Examples of items include ‘I try to grow as a person as a result of the experience’ or ‘I get upset and let my emotions out’. Scores are summed for each scale, with higher scores on each scale indicating a greater tendency towards that style of coping. The COPE has been used widely in research on coping, including in previously published studies with IAPT practitioners (Walklet and Percy, Reference Walklet and Percy2014). The low internal reliability of the Mental Disengagement, Behavioural Disengagement and Suppression of Competing Activities subscales in this study should all be noted. Importantly, low internal reliability for these coping styles has been reported elsewhere in the previously published literature (Carver et al., Reference Carver, Scheier and Weintraub1989; Walklet and Percy, Reference Walklet and Percy2014).
Qualitative data
In addition to the measures described above, trainees were also asked to describe what they took to be the primary sources of stress at the beginning of training. Instructions for the open-text box were as follows: ‘Please briefly outline what you consider to be the primary sources of stress at this stage of the training. (To help us ensure confidentiality, please do not include any information that could identify you or anyone else e.g. your name, name of other people, name/location of your NHS service).’ Open-text boxes were provided for responses to this question.
Procedure
The lead author presented the study to trainees during a teaching session in the induction week of their training. All trainees across two consecutive cohorts were invited to participate. Participation was voluntary and no credit or reward was given for participation. Protected time was provided for both cohorts on two separate teaching days across the first month of their training, in order to encourage participation.
After giving their consent to participate, trainees were given access to a secure survey via the online survey platform Qualtrics. Participating trainees accessed the standardised psychometric measures which they then completed. Participants were also provided with an open-text box in which they were asked to describe what they perceived to be the primary sources of stress at the beginning of the training.
Data analysis
Quantitative data
Quantitative data were analysed using SPSS (version 28). Descriptive statistics were produced for all variables and the relationships between PSS-10 scores and each of the other measured variables (resilience and coping styles) were analysed using Kendall’s τ correlations. The ordinal nature of the data being analysed required the use of a non-parametric measure of correlation (Field, Reference Field2009). Kendall’s τ was chosen due to evidence to suggest that it provides a better estimate of the correlation in the population than Spearman’s rho (Howell, Reference Howell2010).
Qualitative data
Participant responses to the question regarding the primary sources of stress were analysed using the six-stage process of thematic analysis described by Braun and Clarke (Reference Braun and Clarke2006). This involved reading and re-reading the responses to increase familiarisation with the data, before generating initial codes and then subsequently constructing themes. These themes were then reviewed, before being refined and defined and subsequently written into a completed report. The research team met frequently throughout this process, to help support the development of the analysis and to promote a reflective and clear approach.
Results
Quantitative
Perceived Stress Scale (PSS-10)
Across the total sample (n = 90) the mean score for the PSS-10 was 15.7 [standard deviation (SD) = 5.75]. In the original normative data for the measure, a mean score of 13.02 was identified in a general population sample (Cohen and Williamson, Reference Cohen, Williamson, Spacapan and Oskamp1988). A more recent population survey in Germany (Klein et al., Reference Klein, Brähler, Dreier, Reinecke, Müller, Schmutzer, Wölfling and Beutel2016) reported a mean score of 12.74 (SD = 6.67) in the age group most representative of the IAPT workforce (20–39 years).
Connor-Davidson Resilience Scale (CD-RISC-25)
The mean resilience score for this sample (n = 90) was 69.57 (SD = 13.79). The mean score reported in a US general population survey was 79.0 (Connor and Davidson, Reference Connor and Davidson2020). This result indicates relatively low levels of resilience in this sample, placing these trainees in the bottom 25% of previously reported data for the measure (Connor and Davidson, Reference Connor and Davidson2020).
Coping Orientation to Problems Experienced (the COPE Inventory)
Across this sample, ‘Positive Reinterpretation and Growth’, ‘Planning’ and ‘Use of Emotional Social Support’ were the most highly endorsed coping styles. ‘Substance use’, ‘Denial’ and ‘Behavioural Disengagement’ were the least commonly endorsed.
Correlations
Mean scores for each of the variables of interest and the details of the Kendall’s τ correlation with total PSS-10 score are presented in Table 1.
A significant negative correlation was identified between stress and resilience. Significant negative correlations were also identified between stress and ‘Planning’, as well as stress and ‘Active Coping’. Significant, positive correlations were identified between stress and ‘Denial’, and stress and ‘Focus on and Venting of Emotions’. This indicates that for trainees in this sample, higher stress was related to lower levels of resilience, and lower use of ‘Active Coping’ and ‘Planning’. Higher stress was related to higher use of the coping strategies ‘Denial’ and ‘Focus on and Venting of Emotions’.
Qualitative results
Response lengths varied across participants. The mean number of words used across participants was 21, with answers ranging from 1 to 108 words. From these data, one over-arching theme and three individual themes were generated.
The over-arching theme ‘Feeling the responsibility of the role’ connects the three themes, ‘I can find the unknown quite unsettling’, ‘I question my competences’ and ‘Learning, consolidating, and putting it all into practice’.
Over-arching theme: Feeling the responsibility of the role
Taken together, these themes highlight the sense of responsibility that trainee PWPs felt as they entered their new roles. Although in the early stages of their training, trainees reported an awareness of the responsibility associated with clinical work and appeared conscious of the fact that practising effectively in their clinical role meant needing to quickly learn what was perceived to be a large volume of information. A recognition of the connection between their ability to quickly master new content at university, and their ability to practise effectively in service was apparent. For many trainees, the opening weeks of their training were tinged with apprehension and uncertainty, with several reporting feeling unsure both about what was expected of them as trainees, and of their ability to work competently as clinicians. Throughout the section that follows, direct quotations have been used to support and contextualise the interpretive analysis (Braun and Clarke, Reference Braun and Clarke2006) and to demonstrate its credibility and trustworthiness (Morrow, Reference Morrow2005).
Theme 1: ‘I can find the unknown quite unsettling’
For several participants, a significant source of stress in the early weeks of training was attributed to a sense of uncertainty about exactly what to expect from the role they were entering. Participants spoke of not yet knowing ‘what the course entails’ [participant (P) 10] and commented on the ‘lack of clarity around the service and how it works as well as what it looks like’ (P11). As can be seen in the following quotation, this uncertainty was at times presented by trainees both as a source of stress and as a barrier to preparing themselves for what was ahead:
‘I function well when I know exactly what is expected of me and what I need to achieve, so initially I can find the unknown quite unsettling. So I feel that the uncertainty is the main source of stress at the beginning of training.’ (P26)
Elsewhere, several participants repeated feeling ‘uncertain’ (P58, P54, P17) during the opening weeks of their training, and described a sense of ‘anticipation’ associated with ‘not knowing what to do’ (P55).
Theme 2: ‘I question my competences’
This theme describes the tendency amongst trainees to doubt their ability to succeed in the role and to assume that others around them were learning with greater ease. Several trainees spoke explicitly of experiencing ‘imposter syndrome’ (P17, P20) and others described ‘worrying that I will not be a good enough practitioner’ (P34) and ‘feeling like I will not succeed in helping people’ (P4).
This sense of self-doubt and this concern about the possibility of impacting negatively on the people they were training to support can be heard vividly in the concern voiced by participant 27: ‘Will I be able to make a good PWP? Will I let people down by making mistakes in the role?’ (P27).
For several trainees, there was a belief that others in their cohorts appeared more knowledgeable or skilled. Participant 80 for example described ‘Feeling like everyone is understanding the content faster than me and are better at role plays’ (P80).
The concern voiced by many trainees that they were not sufficiently capable extended across multiple aspects of their role. Participant 76 reported ‘not knowing if I can pass exams/essays’, and in response to the question regarding the primary sources of stress at the beginning of training, one participant answered simply, ‘I question my competences’ (P79).
Theme 3: ‘Learning, consolidating, and putting it all into practice’
For many trainees, a primary source of stress in the early weeks of training was the volume of information covered, and the speed at which they felt required to understand and apply it. Trainees spoke of ‘the sheer amount of things to learn’ (P70), describing the experience using words such as ‘intense’ (P21), ‘overwhelming’ (P41) or ‘too much’ (P69). In this context trainees commented that they felt they had no time ‘to reflect before going on to the next activity’ (P68) and spoke of the stress associated with feeling that they were constantly ‘learning, consolidating and putting it all into practice’ (P39).
An awareness of the connection between the information learnt at university and the knowledge and skills needed for their clinical role was apparent in much of what was written. Trainees described, for example, the challenge of ‘remembering all the information that has been given and applying each aspect into practice’ (P63). As such, it appeared that for many trainees, it was not simply a matter of passing through so much information so quickly. Rather it was felt that the ‘primary source of stress is the pace of how fast we’re expected to put things into practice’ (P68).
Discussion
In this study, a convergent parallel mixed-methods design was used to explore stress, resilience and coping in trainee PWPs in the early weeks of their training. The results reported here suggest that within the first month of their role, trainee PWPs experience comparatively high levels of stress. Although no defined cut-offs or severity ratings exist for the PSS-10, the results indicate that trainees experience levels of stress that are higher than those found in the general population (cf. Cohen and Williamson, Reference Cohen, Williamson, Spacapan and Oskamp1988; Klein et al., Reference Klein, Brähler, Dreier, Reinecke, Müller, Schmutzer, Wölfling and Beutel2016). The mean score identified in this sample sits between those recently identified in broadly comparable groups; higher than that identified in psychotherapists working during the COVID-19 outbreak (Probst et al., Reference Probst, Humer, Stippl and Pieh2020), but lower than that found in a recent sample of UK university students (Denovan et al., Reference Denovan, Dagnall, Dhingra and Grogan2019). These scores therefore suggest that stress at the beginning of training may be a point of concern for trainee PWPs.
The mean score of 69.57 (SD = 13.79) on the CD-RISC-25 is below the mean score of 79.0 reported in a large US general population survey (Connor and Davidson, Reference Connor and Davidson2020). It is also below the scores reported in broadly comparable samples such as first year university students in England (Allan et al., Reference Allan, McKenna and Dominey2014) and nursing students in the US (Lekan et al., Reference Lekan, Ward and Elliott2018), in whom mean scores of 75.1 (SD = 12.8) and 73.26 (SD = 10.7), respectively, were reported. Although no established cut-off ratings exist for this measure, the mean score of 69.57 places this group of trainees in the bottom 25% of normative data for the measure (Connor and Davidson, Reference Connor and Davidson2020). This suggests that training or teaching designed to support the development of resilience in trainee PWPs at the beginning of training may be useful, a suggestion supported by recent tentative evidence to suggest that resilience training helps to increase resilience and reduce stress in healthcare professional trainees (Kunzler et al., Reference Kunzler, Helmreich, Chmitorz, König, Binder, Wessa and Lieb2020).
Whilst the correlational nature of the results presented here precludes any inference regarding causality, it is also worth noting that the significant, negative correlation identified between stress and resilience in this current sample is in keeping with well-established literature, throughout which resilience is associated with reduced levels of stress, anxiety and depression (e.g. Connor and Davidson, Reference Connor and Davidson2003; Loprinzi et al., Reference Loprinzi, Prasad, Schroeder and Sood2011; Sood et al., Reference Sood, Prasad, Schroeder and Varkey2011; Tugade and Fredrickson, Reference Tugade and Fredrickson2004). As such, whilst an established body of literature indicates that a combination of both organisational and individual-level factors influence workplace and student stress (Bhui et al., Reference Bhui, Dinos, Galant-Miecznikowska, de Jongh and Stansfeld2016; Pascoe et al., Reference Pascoe, Hetrick and Parker2020), the comparatively high levels of stress and low levels of resilience identified here suggests that the relationship between individual resilience and stress in trainees is an avenue that warrants further exploration.
In this current sample, statistically significant, negative correlations were identified between stress and ‘Active Coping’ and between stress and ‘Planning’. A significant negative relationship between stress and ‘Active Coping’ was also reported in a 2014 study of stress and coping in IAPT staff (Walklet and Percy, Reference Walklet and Percy2014), suggesting that this relationship may be present in IAPT trainee and qualified staff alike. Similarly, the statistically significant, positive correlations identified here between stress and ‘Denial’ as well as that between stress and ‘Focus on and Venting of Emotions’, closely reflect similar findings reported elsewhere (Cushway and Tyler, Reference Cushway and Tyler1996; Walklet and Percy, Reference Walklet and Percy2014), suggesting that these emotion-focused styles of coping may be associated with higher stress in a range of therapy practitioners. Whilst the correlational relationships identified in this study do not demonstrate that ‘Denial’ or ‘Focus on and Venting of Emotions’ lead to higher stress, or that resilience, ‘Active Coping’ or ‘Planning’ help to reduce stress, these relationships may nonetheless be important. Future research to build on the associations identified here and to explore the predictive power of these forms of coping on stress during training will be important. This would help to better understand whether support to enhance resilience or the use of active coping and planning strategies could help to reduce the stress experienced in the early weeks of training. Previously identified stressors for psychological therapy trainees have highlighted factors such as clinical work, supervision and university assessments (Cushway, Reference Cushway1992; Pakenham and Stafford-Brown, Reference Pakenham and Stafford-Brown2012). Being in the first few weeks of their role, however, few if any of the trainees in this current sample would yet have begun receiving supervision or carrying out independent clinical work with patients, and none had yet undertaken university assessments. The qualitative results presented here therefore provide an important context for interpreting these quantitative results. In this way, the mixed-methods approach has supported the development of a fuller understanding of the nature of stress, resilience and coping in the early stages of PWP training than could have been arrived at using either quantitative or qualitative data alone.
The over-arching theme ‘Feeling the responsibility of the role’ suggests that trainee PWPs may experience the early weeks of their training as stressful at least in part due to an awareness of the responsibility associated with training to work as a mental health professional. This finding mirrors previously reported work in which the responsibility associated with clinical work has been identified as an important stressor in healthcare professionals (Agius et al., Reference Agius, Blenkin, Deary, Zealley and Wood1996; Tallentire et al., Reference Tallentire, Smith, Facey and Rotstein2017). Despite having been described in early IAPT literature as a ‘paraprofessional’ role (Farrand et al., Reference Farrand, Confue, Byng and Shaw2008) and having been developed to support people only with mild to moderate difficulties (UCL, 2015b), the emphasis placed here on the responsibility of the role may suggest that the PWP position carries with it a perceived weight of responsibility much like many other health and mental health professions. This finding is potentially important, and perhaps indicative of the way that the PWP role has developed from its paraprofessional beginnings. Trainees entering the PWP workforce today join an established and distinct role, recognised by the Psychological Professions Network as one of 12 professional roles within the psychological professions. Perhaps significantly, recent evidence also suggests that despite having been initially conceived of as a role to support those only with mild to moderate mental health difficulties, PWPs may now routinely work with patients of a broadly comparable level of severity to their high-intensity CBT and counsellor colleagues, whilst simultaneously carrying substantially larger caseloads and working with less intensive training (Pereira et al., Reference Pereira, Barkham, Kellett and Saxon2017). As such, this finding may potentially be reflective of an important shift and evolution in the nature of the PWP role.
The theme ‘I can find the unknown quite unsettling’ described how trainee PWPs entered the training feeling unclear about expectations regarding multiple aspects of their role. Whilst many trainees will have prior experience studying in higher education or working in the field of mental health, the specific expectations associated with this role, their employing service and the university they are now enrolled with, seem for many to bring with them both something new and a sense of uncertainty. These results, in which uncertainty is described as an important early source of stress for trainees, can be seen as aligning with an existing body of research which indicates that uncertainty in the workplace is associated with reduced workplace wellbeing (Schmidt et al., Reference Schmidt, Roesler, Kusserow and Rau2014). The significance of this uncertainty as a stressor for trainees suggests that education providers and services involved in the training of PWPs may helpfully consider ways to provide additional clarity regarding expectations for trainees in the early weeks of their role.
The theme ‘I question my competences’ suggests that trainee PWPs experience self-doubt in the early weeks of their training, questioning their ability to adequately succeed with regard to multiple aspects of their roles. This finding mirrors those reported elsewhere in the literature (Bennett-Levy and Beedie, Reference Bennett-Levy and Beedie2007; Duryee et al., Reference Duryee, Brymer and Gold1996; Pakenham and Stafford-Brown, Reference Pakenham and Stafford-Brown2012) which suggest that trainee self-doubt is common amongst those training to work in psychological therapy. Whilst evidence exists to suggest that self-perceived competence generally rises over the duration of training (Bennett-Levy and Beedie, Reference Bennett-Levy and Beedie2007), a degree of self-doubt and a tendency to question one’s competence may in fact be an at least occasional feature of psychological therapy practitioners’ experience throughout their careers (Hannigan et al., Reference Hannigan, Edwards and Burnard2004). Given such findings, an attempt to normalise this aspect of trainees’ experience may be helpful for those involved in the training of PWPs.
The theme ‘Learning, consolidating and putting it all into practice’ adds a potentially important dimension to the existing evidence base regarding the perceived sources of stress in psychological therapy practitioners and trainees. Several previous studies have pointed towards a relationship between the volume of clinical or academic work to be covered, and levels of stress or burnout (Cushway, Reference Cushway1992; Westwood et al., Reference Westwood, Morison, Allt and Holmes2017). This theme suggests that for PWP trainees, however, the stress experienced followed not simply from the volume of work to be covered, but the perceived need to move so quickly into applying this new learning practically both during in-class role plays, and through clinical work in service. Given the emphasis placed on reflection for developing therapeutic competence (Bennett-Levy, Reference Bennett-Levy2006), the experience described here by trainees of moving quickly between topics may be important.
Strengths and limitations
The use of open questions to explore the primary sources of perceived stress in trainees represents a significant strength of this study. To date, there has been no published study exploring the perceived sources of stress during IAPT training. Existing studies in related fields such as clinical psychology training (e.g. Cushway, Reference Cushway1992) have frequently relied on the use of questionnaires and quantitative approaches to address the question regarding the causes of stress. Whilst such research has undoubtedly generated important and useful findings, such work is always and necessarily constrained by the remit of the measures used or options provided. As such, research such as that presented here, which uses open-ended questions to explore trainees’ individual perception regarding the sources of stress during training is much needed.
This study has several limitations. Firstly, whilst the decision not to gather demographic information on participating trainees represents a strength of the research in the sense that it provided a truly anonymous environment for trainees to comment openly in, it nonetheless limits the ability to say with certainty whether any demographic information unique to this group of trainee PWPs may have affected the results. Additionally, whilst COVID-19 was noticeably absent from almost all trainee responses regarding the primary sources of stress, the fact that data were gathered during the pandemic and at a time when trainees were receiving all aspects of their training remotely, potentially limits the extent to which results can be helpfully compared with those gathered at other times. Although participating trainees were employed in a range of services including NHS and third sector organisations based across a broad geographical region, the fact that trainees were all students at the same university means that factors specific to that training provider may potentially have impacted results. The cross-sectional nature of the study prevents any inference regarding the direction of the relationships identified here, and consequently, future research including longitudinal work that explores these relationships over time, is needed to build on these findings. Finally, whilst the low internal reliability identified for several coping subscales is in keeping with those reported elsewhere in the published literature (cf. Carver et al., Reference Carver, Scheier and Weintraub1989; Walklet and Percy, Reference Walklet and Percy2014), they indicate a need to interpret the results for the relevant coping styles with caution.
Implications for trainers
Whilst replication and expansion of these findings is needed before definitive recommendations can be made, trainers may consider a number of possible adaptations in light of the results presented here. Results suggest that education providers and supervisors should consider addressing and normalising professional self-doubt early on in the training, whilst also acknowledging and addressing the challenge of quickly applying large volumes of new learning. Similarly, attempts to provide clarity in terms of clinical and academic expectations at the outset of training may be helpful. Finally, despite the cautionary notes sounded above regarding the correlational nature of the results reported here, when considered in the context of the existing literature regarding stress, resilience and coping, our findings also suggest that training in resilience building and adaptive forms of coping may be useful for trainee PWPs as they enter into their new roles.
Conclusion
In the first month of training, trainee PWPs reported above average levels of stress and below average levels of resilience, when compared with normative data for the measures used. Significant negative correlations were identified between stress and resilience, stress and ‘Active Coping’, and stress and ‘Planning’. These findings suggest that those trainees experiencing lower levels of stress were those who rated themselves as more resilient and more likely to use ‘Active Coping’ and ‘Planning’ styles of coping to deal with the stressors experienced over the early weeks of their training. The significant positive correlations identified between stress and ‘Denial’, and stress and ‘Focus on and Venting of Emotions’ indicate that those trainees experiencing higher levels of stress in the early weeks of training were also those more likely to seek to deny the nature of the challenges encountered, or to focus on the emotions that these challenges generated. The use of open-text questions to gather qualitative data regarding the perceived sources of stress during training was a novel development in the psychological therapy trainee literature, and helped to contextualise the quantitative results reported here. The results suggest that the uncertainty regarding what is expected of them as trainees, a tendency to doubt their ability to perform well in the role, and a sense that information had to be moved through quickly and applied practically were the primary sources of stress at the beginning of training. Future research that builds on the relationships identified here and assesses the trajectory of stress over the course of PWP training will help to further develop understanding of this important topic.
Key practice points
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(1) In the early weeks of their training, trainee PWPs reported higher levels of stress and lower levels of resilience than those found in the general population.
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(2) Statistically significant negative correlations were identified between stress and resilience, and between stress and ‘Active Coping’ and ‘Planning’. Statistically significant positive correlations were identified between stress and ‘Denial’ and ‘Focus on and Venting of Emotions’.
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(3) Three themes regarding the primary sources of stress at the beginning of training were generated. These themes suggest that uncertainty about what to expect from the role, professional self-doubt, and a sense that information had to be quickly absorbed and applied in practice, were all significant sources of stress for trainee PWPs at the beginning of training.
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(4) These three themes were connected by an over-arching theme suggesting that trainee PWPs experience stress in relation to the perceived responsibility of the role.
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(5) Trainees, IAPT services and education providers can take practical steps that build on this research to help reduce the stress experienced in the early stages of PWP training
Data availability statement
The data that support the findings of this study are available from the corresponding author (J.O.) upon reasonable request.
Acknowledgements
None.
Author contributions
Joel Owen: Conceptualization (lead), Formal analysis (lead), Investigation (lead), Methodology (lead), Project administration (lead), Writing – original draft (lead), Writing – review & editing (lead); Solange Cross: Formal analysis (supporting), Project administration (supporting), Validation (supporting), Writing – review & editing (supporting); Vasiliki Mergia: Formal analysis (supporting), Methodology (supporting), Project administration (supporting), Writing – review & editing (supporting); Paul Fisher: Conceptualization (supporting), Formal analysis (supporting), Investigation (supporting), Methodology (equal), Project administration (supporting), Supervision (lead), Validation (supporting), Writing – review & editing (supporting).
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflicts of interest
The authors declare none.
Ethical standards
The authors confirm that they have abided by the ethical principles of psychologists as set out by the BABCP and BPS, and have adhered to relevant codes of conduct. Ethical Approval for this study was sought and obtained through the Ethics Committee of the School of Education and Lifelong Learning at UEA on 11 August 2020. Informed consent was provided by all participants in this study.
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