Building resilience in the Improving Access to Psychological Therapy (IAPT) Psychological Wellbeing Practitioner (PWP) role: a qualitative grounded theory study

Abstract Aim: Staff retention, particularly in the Psychological Wellbeing Practitioner (PWP) workforce, has historically been challenging for Improving Access to Psychological Therapy (IAPT) services. This study sought to develop an explanatory model of the resilience-building process in PWPs working within the IAPT programme. Method: A qualitative design was conducted, using a grounded theory methodology. Participants were recruited from two IAPT services in the National Health Service (NHS), which were part of the same Mental Health Trust. Ten PWPs were interviewed via videoconferencing using semi-structured interviews. Results: An explanatory model of resilience in PWPs encompassed three phases: the experience of work-related challenges, the connection with their values and the related appraisal of adversity in resilient ways, and the implementation of effective coping strategies. Conclusions: The model highlights that PWPs develop resilience through values-based sensemaking and by proactively engaging in effective coping mechanisms. This study contributes to the current understanding of the process of resilience in PWPs. More research is needed to explore the developmental processes underlying PWPs’ resilience. The implications of the findings in relation to existing conceptualisations of resilience, staff wellbeing and retention are explored. Recommendations for future research are also given.


Introduction
Over the past fifteen years, psychological services in England have been transformed by the introduction of the Improving Access to Psychological Therapies (IAPT) programme, which aimed to expand access to evidence-based psychological treatment for people with common mental health difficulties, such as anxiety and depression (Clark, 2018;Richards and Whyte, 2009).One of the key features of IAPT is its adherence to clinical guidelines provided by the National Institute for Health and Care Excellence (NICE).NICE guidelines recommend a stepped-care model of service delivery, offering the least intrusive interventions first (National Institute for Health and Care Excellence, 2011).Currently, the IAPT programme offers access to almost a million clients and treats over 560,000 clients per year (Clark, 2018).
In addition to the more traditional High-Intensity CBT Therapist (HIT) role, IAPT introduced the Psychological Wellbeing Practitioner (PWP) role to ensure the provision of low-intensity CBT for mild-to-moderate anxiety and depression (Richards and Whyte, 2009;Robinson et al., 2012).Low-intensity treatment can be delivered face-to-face, over the telephone or using online platforms.To undertake this work, PWPs complete a one-year undergraduate or postgraduate certificate in low-intensity CBT based on a national curriculum (University College London, 2015).Trainee PWPs are employed by IAPT services and spend roughly three to four days working in service, and the remaining days undertaking university work.PWPs receive a minimum of one hour per week of individual case-management supervision and also regular group clinical skills supervision (Green et al., 2014).
IAPT services have consistently reported high levels of staff turnover in their PWP workforce (National Collaborating Centre for Mental Health, 2018).Whilst many PWPs move into highintensity CBT training after two years of clinical experience (NHS England & Health Education England, 2016), research has highlighted that, despite receiving individual case-management and group clinical skills supervision, as well as general NHS and employer assistance support, PWPs experience high levels of stress and burnout, which might contribute to these high levels of turnover, including staff leaving IAPT altogether.Steel et al. (2015) found that PWPs' stressful work involvement, and wider service-related issues such as service demands and autonomy, were the most significant predictors of burnout.Westwood et al. (2017) found that the prevalence of burnout was 68.6% among PWPs and 50.0%among HITs.Hours of overtime predicted higher levels of burnout and hours of clinical supervision predicted lower levels of burnout.The likelihood of burnout increased with the number of hours of telephone contact among PWPs who had worked in the service for two or more years.In the wider literature on therapist burnout, factors such as younger age, neuroticism, and emotion-focused coping have also been associated with higher vulnerability for burnout (Simionato and Simpson, 2018).Delgadillo et al. (2018) investigated the impact of occupational burnout on depression and anxiety treatment outcomes in IAPT, finding that therapist burnout had a negative impact on client treatment outcomes.Improving PWP retention is a key IAPT objective (National Collaborating Centre for Mental Health, 2018) and the National Health Service (NHS) in England has identified staff wellbeing as a critical factor in promoting resilience in its workforce (NHS England, 2016).
There have been numerous attempts to define and standardise the concept of resilience.Heterogeneity in adversity and risk experienced, as well as in the levels of competence obtained, has led to the development of competing ideas and definitions of resilience (Luthar et al., 2000).However, despite this variability, many definitions encompass some common elements: exposure to significant levels of adversity, threat or trauma; the ability to recover from such experiences; and achieving better-than-anticipated outcomes (Luthar et al., 2000;Masten and Barnes, 2018).Historically, research on resilience has focused on identifying risk and protective factors to understand how disadvantaged people, especially children, can thrive in adverse circumstances (Garmezy, 1970;Garmezy, 1974).
More recently, research on resilience has shifted its focus towards understanding key underlying processes, putting emphasis on how these factors contribute to positive outcomes (Cicchetti, 2010).This new attention to the underlying processes of resilience is key to generating theories and identifying preventative and intervention strategies for people coping with adversity.Resilience has therefore been understood as the result of interactions taking place across multiple levels, shaped by processes occurring between the individual and the macro-level systems of culture, society and ecology (Masten and Barnes, 2018;Ungar, 2011).This study aims to draw on these newer understandings of resilience-building processes to explore the individual, organisational and psychosocial dynamics that contribute to the development of resilience in PWPs.
Due to the recent development of IAPT, research regarding PWPs has been scarce (Green et al., 2014).There is very little research on resilience in PWPs, and existing research is mainly quantitative.A recent study in IAPT investigated the impact of mindfulness and resilience on therapist effectiveness, finding that more effective therapists reported higher levels of mindfulness and resilience, compared with less effective therapists (Pereira et al., 2017).Similarly, Green et al. (2014) found that PWPs whose patients had higher rates of reliable and clinically significant improvement, reported greater resilience and organisational skills, and felt more knowledgeable and confident in delivering therapy.
As can be seen, research on resilience in IAPT so far has focused on factors and associations investigated within cross-sectional analyses, rather than exploring how resilience occurs in PWPs and how they benefit from resilience-building processes.Existing theoretical models of resilience in other mental health professionals, such as social workers and family therapists, stress the importance of being able to adapt to challenging circumstances, the role of individual and environmental factors, the integration of practice within the self, the benefits of positive appraisals of adversity and the need to operate within a flexible environment where problems can be addressed effectively (Clark, 2009;Van Breda, 2011).These models can help to inform research on PWPs' resilience as they can experience similar work-related and personal difficulties.
The aim of this study is to fill this gap in the existing literature by constructing a theoretically sufficient grounded theory (Strauss and Corbin, 1998) of the resilience-building process in the PWP role, and how this impacts on them personally and professionally.Making sense of this process of resilience-building can help services to address individual, occupational and organisational difficulties, and provide a greater understanding of what enables PWPs to thrive in the role, despite the chronic work-related stress they face.

Study design
A critical realist perspective was taken, which postulates that the data, their interpretation and the related findings might not provide direct access to all reality as they only hold true within their specific contexts, structures and interactions (Bhaskar, 2008;Roberts, 2014;Willig, 2013).Grounded theory was used to analyse the data, employing different coding strategies to identify categories of meaning that led to the development of a theoretically sufficient explanatory model.This study followed the methodological guidelines outlined by Strauss and Corbin (1998), which recognise the active role of the researcher in interpreting data and enhancing theoretical sensitivity (Corbin and Strauss, 2008).

Participants
The study recruited PWPs from two IAPT services within the same large NHS Mental Health Trust.Eligible participants were required to (a) be 18 years old or over, (b) have completed a oneyear postgraduate or undergraduate certificate based on a PWP national curriculum, and (c) work as a fully qualified PWP within IAPT.The study did not aim to specifically target PWPs who described themselves as resilient.Rather, the study aimed to recruit participants who could talk about the process of developing resilience, and the potential challenges and barriers related to this process, regardless of whether they considered themselves resilient.
The recruitment of PWPs was facilitated by IAPT service leads, who cascaded relevant information about the study to PWPs in their service, who then contacted the first author if they were interested in taking part in the study.Eligible participants who expressed an interest were sent a participant information sheet and a consent form to sign prior to taking part in an interview.Ten participants (nine female and one male) were recruited.No eligible participants were excluded or dropped out from the study.The average duration of clinical experience since qualification was 27 months, ranging from 2 months to 12 years.
Participant confidentiality was preserved by anonymising recorded interview data, transcripts and verbatim extracts.Recruiting participants from more than one IAPT service also helped to ensure participant anonymity.Given the small sample size of this study, to ensure anonymity, participants' demographic and socio-economic information was not included.

Data collection
Video-recorded semi-structured interviews were undertaken with PWPs.The duration of the interviews ranged from 54 to 80 minutes, with an average of 67 minutes.These were conducted remotely by the first author using Microsoft Teams.An interview schedule was utilised as an initial guide, including questions that explored the process of developing resilience in the PWP role.Open questions such as 'what is resilience for you?', 'have you been able to develop resilience in your role?', 'how have you developed your resilience?' and 'what has helped you develop resilience?' were included.The interview schedule remained flexible and open so that the conversation could be actively shaped by the participants' reflections, views and language in a natural way.The iterative nature of grounded theory implied the progressive redefinition of the interview schedule within and across interviews, taking into consideration the emerging data, codes and analysis (Strauss and Corbin, 1998).Therefore, in line with theoretical sampling, interviews were transcribed and coded while recruiting participants.This iterative process was conducted until theoretical sufficiency, rather than saturation, was achieved.It has been proposed that theoretical sufficiency can be reached with 6-10 interviews (Clarke and Braun, 2013).

Data analysis
Interviews were transcribed and the data analysed using a qualitative grounded theory methodology.This methodology was chosen as it allowed the researchers to generate an explanatory model of the conditions that gave rise to the process of developing resilience in PWPs, which was the main aim of this study, particularly as little was known about this process (Strauss and Corbin, 1998).
This led to the development of a theoretical model describing how PWPs build resilience in their role.The study followed the methodological guidelines set by Strauss and Corbin, which are based on a three-stage model of data analysis: open, axial and selective coding (Corbin and Strauss, 1990;Corbin and Strauss, 2008;Strauss and Corbin, 1998).The analytical process was carried out using NVivo qualitative data analytical software (Release 1.5.2,2021).Open coding involved an openminded, line-by-line coding.The emerging codes were labelled to establish categories and a constant comparative approach was employed to achieve theoretical sufficiency.The second stage, axial coding, iteratively explored the relationships between codes, highlighting how they related to each other.This process was facilitated by the emergence of conditions, contexts, strategies, actions and interactions of categories, as well as the consequences of these.The third stage of analysis, selective coding, involved the identification of core categories or concepts, from which the theoretical model of the resiliencebuilding process in PWPs developed.This model was obtained by conceptualising a storyline around the core category while constantly exploring the connections between this and the other categories identified in the analysis (Corbin and Strauss, 2008;Strauss and Corbin, 1998).
The development of all codes and categories, as well as the resulting theoretical model, were reviewed and discussed with the second and third author throughout the data analysis process.Data extracts were slightly edited to preserve anonymity and improve readability, when needed.

Reflexivity and rigour
Theorising contextual effects is one of the key advantages of qualitative research, which aims to gain awareness of participants' views and settings, and the multi-level interactions between contexts (Cohen and Crabtree, 2008).Two authors of this study have worked as PWPs in the past.
This direct experience enabled them to develop a better understanding of the participants' contexts and perspectives (Yardley, 2000;Yardley, 2017), in line with the critical realist framework adopted in this research.In order to promote a trusting, open and transparent rapport, participants were made aware of the first author's professional background prior to their interviews.
The first author used a self-reflective diary and memos to record significant events and acknowledge personal, social and cultural contexts throughout the research process.The diary helped the researcher to reflect on their own observations, experiences, interpretations and biases.The authors regularly met to discuss and agree on identified themes, and explore the development of the theoretical model.Furthermore, the project sought to ensure quality and rigour by using Yardley's (2000Yardley's ( , 2017) ) evaluative criteria and framework, which informed and guided the research process.

Results
Participants described how the process of building resilience in their role developed through connection with their own values and the appraisal of work-related challenges in relation to those values.Three main phases of this theoretical model were identified: experiencing work-related challenges; connecting with their own values and appraising adversity in relation to those values; and implementing proactive coping strategies.This developmental process was established to have individual and systemic dimensions, which impacted on the development of resilience over time.Figure 1 shows the key elements of this dynamic resilience-building process.The arrows indicate how elements interlink, and the relationship between them.
Participants described how finding meaning and purpose encourages them to implement coping strategies when facing adversity, fostering their willingness and ability to cope with difficulties.Participants spoke about feeling that what they do matters and that they are in the role for a reason, which enables them to adapt to difficult circumstances and build resilience over time.They reflected on the meaning of 'helping others', 'making a difference' and 'changing people's lives'.This process of awareness of their values and how they are being nurtured through day-today work allows PWPs to navigate and overcome the challenges they experience in their role, reaffirming their sense of purpose and identity.For this group of PWPs this awareness is therefore a key part of the resilience-building process, and how they face and adapt to adversity more generally.Each part of the grounded theory model will be evidenced in turn.

Work-related challenges
The first phase of the theoretical model is related to the difficulties PWPs experience in the role, which affect their experience of resilience.These challenges are important to consider as they are Behavioural and Cognitive Psychotherapy an integral part of the resilience-building process that occurs in PWPs over time.Two main dimensions were identified: systemic and individual challenges (see Table 1).

Individual challenges
Individual challenges were mainly related to lack of professional and personal experiences.
Participants highlighted how lacking personal or professional experience could contribute to the development of work-related challenges.Participant 8 talked about not having had particular life experiences prior to working as a PWP as a barrier to thriving in the role.Lack of prior professional experience and training was also described as a significant challenge for PWPs, who may find it difficult to work clinically and manage their workload.Participant 1 highlighted the importance of prior work experience when managing risk and their time more generally.

Systemic pressures and demands
Participants emphasised the impact of the systemic challenges they experienced on their ability to develop and maintain resilience.Work-related pressures and demands, particularly the high volume of clinical work and the related time constraints, were identified as the main challenges that PWPs experience, as Participant 5 explained.Participants reflected on the difficulties associated with balancing administration and clinical work, particularly when managing risk and safeguarding concerns, as Participant 2 highlighted.
Participants also talked about the stress related to dealing with a high volume of clinical work and the lack of opportunity to reflect on it.Participant 5 spoke about the impact of not being able to process their own feelings and emotions, when needed.

Individual challenges
'I think PWPs who haven't had that kind of life experience already, may find it a bit harder than maybe, PWPs that have had some life experience, which has made them either question or go through hard times and see how they are able to manage to cope with those difficult times.' (Participant 8) 'I'm thinking of personal experience with certain colleagues who haven't come with experience and don't know what to expect.They've never kind of dealt with risks, they've never dealt with difficult interactions, and they struggle quite badly to do that.So, I think a really important part of this resilience is having experience of it, and working and organising and managing your time.' (Participant 1) Systemic pressures and demands 'I think sometimes, when it is so relentless, yes, there is that sort of okay, I can build up this barrier between work and home, but if it's just absolutely relentless and nothing seems to be getting easier at work, that can definitely be difficult because you just don't have that breathing space at all.' (Participant 5) ' : : : when I feel really overwhelmed, when there is too much going on, and when I've got referrals to the crisis team or a lot of referrals to the community mental health team or cases that are just not appropriate for wellbeing (the IAPT service), I'm overwhelmed not only with the difficulty that the patients experience, but also having to do all the paperwork.Then I feel like sometimes it's just too much to cope with and I can feel like being really overwhelmed.'(Participant 2) 'But maybe in the long-term that (not being to talk about their own feelings and emotions) doesn't help because you've got all this stuff that you haven't spoken about or processed.But ultimately, yes, if there are times when I haven't really been able to open up or talk to people when I need to, yes, I think that is very difficult because then I think there is something that I've taken on that I just haven't really processed or haven't shared when I might have wanted to.' (Participant 5)

Connecting with values and appraising adversity in relation to values
The core category of this theoretical model was the participants' connection with their own values and the subsequent appraisal of work-related adversity in relation to those values.Rather than experiencing challenges as overwhelming and unsurmountable barriers, getting in touch with their beliefs allowed the participants to place adversity in a wider context, acknowledging the need to overcome it in order to stay true to the values they believed in.Participants talked about how finding meaning in their day-to-day work encouraged them to take action and proactively implement coping strategies when facing challenges (see Table 2).Participant 3 described how powerful and motivating this process is.It is through this sense-making process that participants were able to adapt to work-related difficulties and develop resilience in their role.Similar to the first phase of the theoretical model, this core phase has an individual and a systemic dimension.

Individual dimension
Participants talked about getting in touch with their values when facing challenges as the key element of their resilience-building process.Finding meaning and purpose in their day-to-day work enabled them to build resilience over time, as Participant 2 explained.Participant 8 described how reminding themselves of the meaning of their work was particularly helpful when dealing with highly emotive situations.Participant 7 talked about how their values act as a

Discussion
Given the enduring occupational stress and the high burnout and turnover rates in IAPT services (National Collaborating Centre for Mental Health, 2018;Owen et al., 2021;Westwood et al., 2017), this study sought to develop an explanatory model of the resilience-building process in PWPs to gain a greater understanding of how they overcome and adapt to work-related adversity.Participants described the process of developing resilience through three main phases.The first phase involved the experience of dealing with work-related challenges.The second and core phase of this process was the participants' connection with their values and the subsequent appraisal of work-related difficulties.The third phase highlighted how participants developed resilience through the implementation of coping strategies, following their values-based appraisal of work-related challenges.
In line with existing conceptualisations of resilience involving other mental health professionals, such as social workers and family therapists (Clark, 2009;Van Breda, 2011), the current findings suggest that resilience involves the experience of adversity; implies the ability to adapt or 'bounce back'; represents a dynamic and fluid process that occurs over time; and facilitates wellbeing and coping abilities.The findings seem to fit particularly well with recent conceptualisations of resilience as something relevant in the context of everyday difficulties, rather than solely in the context of significant adversity (Fletcher and Sarkar, 2013), and also as something which involves the interaction of multiple systems or processes (Masten and Barnes, 2018;Ungar, 2011).The findings also mirror existing theoretical models of resilience in psychological therapists and mental health staff as a process of gradual adaptation to work-related challenges (Clark, 2009;Van Breda, 2011).Most importantly, the study highlighted that it is the values-based sense-making that PWPs go through that promotes the adoption of constructive attitudes towards overcoming adversity, thus fostering resilience.

Individual coping strategies
'I always like to have some annual leave to look forward to, even if it's in say 5-6 weeks' time : : : making sure that I've always got something that I'm looking forward to.That's something that I've found really useful to help keep resilient too.' (Participant 10) 'Sounds a bit silly, but I do practise the interventions.I do do BA (behavioural activation) on myself.I do do these things on myself, classification of worries : : : ' (Participant 1) Developing work-related boundaries 'I think you almost have to build up this wall or barrier, you know, this is my work life and this is my personal life and no matter what happens today, I still want to be able to enjoy my life outside of work.' (Participant 5) 'I want them (their clients), at the end of our treatment sessions, to go with these techniques, that I'm there to guide them through so that they use them going forward : : : but for me, after doing the role for a while, I realise that by doing that, that boundary-setting is really important and making the sessions as structured as possible.'(Participant 8) 'I think it's definitely something, as you grow as a practitioner, learning to put those, I wouldn't say they were boundaries, but learning to separate and compartmentalise those things is absolutely a skill.Knowing that I've done everything that I can do and this is my time now, this is my personal life and leaving that in that box.' (Participant 10) Systemic and relational strategies 'I am not entirely sure where are the boundaries, but, you know, to just feel like your supervisor's got your back, like there's someone in your corner, that there's someone that you can trust, that you can go to.Whether you need to cry about something that happened at work, or, you know, it's an emotional job.' (Participant 4) ' : : : we've created our own kind of resilience space with my colleagues, which is really nice.
So, in that space, we do help each other.I'm not necessarily sure if they've been noticing or what their experience of me is in it, in regard to my resilience, but I think overall as a team or the few people that that are in this group, we do support each other's resilience.' (Participant 4) 'If I didn't have them (colleagues), I don't know if I would still be in the role.We've got the team chats that we stay in touch with, we basically speak every day.' (Participant 6) For the current participants, the first phase of the resilience-building process described the experience of work-related difficulties.The difficulties associated with managing a large volume of clinical work and high caseloads appear to be significant barriers to PWP effectiveness, particularly when combined with poor or limited access to clinical support and supervision (Owen et al., 2021;Westwood et al., 2017).One potential explanation may be that practitioners who deal with a high volume of clinical work and experience time pressure find it hard to balance the available resources and demands they face.This imbalance fosters a perceived lack of control and autonomy in their role and limited participation in decision-making processes, which can lead to low job satisfaction, stress and burnout (Iannello et al., 2017;Morse et al., 2012).
The second and core phase of the grounded theory described the participants' connection with their own values to appraise the difficulties they faced.Participants shared that getting in touch with their most meaningful values, such as wanting to help others and making a difference in people's lives, enabled them to develop resilience.Most of the relevant literature on therapist burnout has emphasised the need to target negative factors in order to reduce burnout (Morse et al., 2012).The findings of this study stress the importance of exploring sense of purpose and meaning in order to increase therapist involvement, job satisfaction and resilience.It is possible that the focus on achieving national targets in IAPT services moves therapists away from their true values and aspirations, which affects their sense of agency, and their willingness and ability to adapt to challenges.As other conceptualisations of resilience have theorised, the role of values and beliefs is key in appraising work-related stressors as comprehensible, manageable and meaningful (Hou and Skovholt, 2019;Van Breda, 2011).
The third phase of the resilience-building process in PWPs described the implementation of individual, work-related and systemic coping strategies.PWPs seem to elicit resilience through the use of wellbeing and self-care strategies, such as taking breaks, having time off and engaging in pleasurable activities.It appears that the emphasis on their wellbeing and the related engagement in meaningful and enjoyable activities allows PWPs to detach from work-related concerns and focus on cultivating their own interests.Research has suggested that the regular implementation of self-nurturing behaviours fosters therapists' ability to develop their sense of identity (Hou and Skovholt, 2019).Similarly, PWPs with strong work-related boundaries, such as good organisational and time-management skills, tend to be more resilient and proactive in their approach, as well as more clinically effective (Green et al., 2014).Therapists with firm workrelated boundaries are less likely to take on additional tasks and work overtime, thus maintaining high levels of resilience and preventing burnout (Westwood et al., 2017).The systemic and relational strategies discussed by the participants of this study included relying on peer support, managerial and clinical supervision.Therapists seem to elicit support, encouragement and normalisation of their difficulties through the interactions with their peers, reducing self-doubt and increasing self-confidence (Clark, 2009;Jones and Thompson, 2017).Feeling supported by the supervisor and building a positive relationship based on trust has been shown to boost therapist resilience (Rothwell et al., 2019).This trusting relationship facilitates open and honest discussions in which beliefs and values can be explored safely, thus encouraging therapists to stay true to their belief system (Rothwell et al., 2019).

Clinical implications and recommendations
Staff wellbeing and retention are significant areas of concern for IAPT services as practitioners deal with a very high volume of clinical and non-clinical work, which contributes to the longstanding work-related challenges they face.Understanding the processes that support the development of resilience in clinical roles therefore has the potential to address these concerns.These are important issues to tackle as poor wellbeing has been associated with a higher intention to leave the NHS (Summers et al., 2020) and low levels of resilience have been associated with higher levels of stress in PWPs (Owen et al., 2022).
The process of developing resilience described by the participants highlighted the key role of values-based sensemaking and the subsequent use of effective coping mechanisms in managing work adversity.Services should consider the promotion of a values-based culture where therapists feel able to nurture their beliefs and values, as this has been shown to encourage the appraisal of work-related difficulties in resilient ways (Van Breda, 2011).The importance of establishing a values-based culture has been emphasised by the UK's NHS, which has consistently promoted its core values and principles through the publication of the NHS Constitution (NHS England, 2013).Services could consider the use of self-awareness and reflective practices, such as mindfulnessbased activities and narrative exercises exploring meaningful clinical experiences, as these have been shown to enhance sense of purpose and job satisfaction, thus increasing resilience in the workplace (Krasner et al., 2009;Morse et al., 2012;Robey et al., 1991).
Services should promote self-care and wellbeing strategies, and encourage therapists to maintain effective work-related boundaries.It is important for services to regularly emphasise and promote these strategies to nurture a culture of compassion and empathy for both clients and staff, where ethical practice is nurtured.As also acknowledged by NHS England, effective leadership (NHS Leadership Academy, 2013), training and supervision all contribute to fostering this organisational culture in services (Robey et al., 1991;Shakeel et al., 2019;Simionato et al., 2019).Therapist wellbeing should also be supported systemically through the development of peer networks.This can be achieved by designing initiatives that bring professionals together, such as practice-based courses and training, relaxation and leisure activities (Simionato et al., 2019).

Limitations and future areas of interest
Being a qualitative study, this research does not aim to generalise its findings to other populations of PWPs in a statistical sense (Myers, 2000).However, quantitative and mixed-method studies with larger sample sizes can seek to build on these findings, and might achieve further generalisability and provide more insight into the process of developing resilience in PWPs.
This study did not use any measures of resilience that could have helped to contextualise the sample and, in turn, the findings.Future research on resilience in PWPs could therefore include specific measures of resilience to further contextualise the sample, the settings and the findings.
As all qualitative research is inherently subjective (Starks and Trinidad, 2007), the authors' personal opinions and biases might have influenced the interview process, transcription, analysis and interpretation of data, as well as the related findings.Therefore, it is important to acknowledge potential issues of bias, credibility, coherence and transparency (Yardley, 2000;Yardley, 2017).However, the authors mitigated these risks by enhancing rigour and trustworthiness, particularly through the implementation of techniques that make participants feel at ease during interviews, such as rapport building, the use of reflexivity tools, such as reflective diaries and memos, and regular peer debriefing and scrutiny.Future research could build on these findings to increase transferability between services and contexts, and more generally the breadth of therapist experiences.While this research did not aim to generalise its findings, the patterns, experiences and perspectives included in this study could be applicable to other contexts and settings, such as those related to other psychological therapists and mental health staff.This could be achieved, for example, by carrying out studies with larger sample sizes and involving other IAPT therapists and practitioners, such as HITs, counsellors and psychologists.Studies including students and trainees might provide a deeper developmental understanding of the resilience-building processes in PWPs.

Conclusion
This study aimed to develop an understanding of the resilience-building process in the IAPT PWP role through qualitative interviews with a small sample of PWPs.Findings highlighted that this cohort of PWPs developed resilience through the connection with their values and appraising the challenges they faced in relation to their beliefs and values.For the participants getting in touch with their values enabled them to find meaning and purpose in their difficulties, which enabled them to overcome adversity, including through using effective coping strategies.Given the enduring occupational challenges IAPT practitioners deal with, services and training programmes should promote a values-based culture where PWPs can be true to their values and encourage the use of effective individual and systemic coping strategies.Further research with larger sample sizes and different methodological approaches is needed to increase transferability.

Table 2 .
Connecting with values and appraising adversity in relation to values get a sense of energy, actually, almost like energised by it.I'm trying to think of the right words, but I think yeah, the word energised is probably the word, that almost feel your body language changes, you're slightly more alert, but not Battle Stations alert, alert as in I need to be on my game here and I'm here to help and I need to be supportive and I need to be as professional as I can be, because this is a situation that requires it.'(Participant 3) Individual dimension 'I don't think if I saw that what I'm doing doesn't have any result on people's lives, then I wouldn't be able to do that job, I'd definitely feel too overwhelmed.But, actually, seeing that you are making changes, that in itself builds your resilience and ability to cope with the other difficult situations that you experience, knowing that feeling needed and feeling like you are in this job for a reason, which is usually wanting to help other people.And when you are meeting that goal, that helps with adapting to maybe more difficult days, still having the awareness that what you do makes sense and makes a difference.'(Participant 2) ' : : : if you're having that kind of moment where you think, you have one of those days where everyone is risky or there is lots of work to do, or you're just feeling overwhelmed, reflecting on those experiences where you have helped people, you have got them through, can be really helpful because it reminds you as to why you're here.'(Participant 8) ' : : : they (their values) are a good motivator, I guess.If I'm having a bit of a bad time or if I'm not feeling as sharp or whatever, I do try and give myself a bit of a kick, I suppose, to be like, okay, well, this is who you are, this is what you are, this is the rules that you live by, so, to speak.You're in this job for a reason, you want to help people, and then that can be quite helpful, just to give that little bit of encouragement, I suppose.
' (Participant 7) Systemic dimension 'It's just again the reason why I do love the role, and I do think this environment, a lot of what I've said is only possible because of my manager : : : So it's quite a nice environment that's fostered at the moment in my team.A lot of those values are encouraged, I suppose, in this particular role and particular team that I'm within.It means a lot to me, and that's what makes me think there is longevity to this role.'(Participant 1) ' : : : what I love about the PWP role, and this is also true of working with other PWPs because, you know, people are generally empathic and reflective.It is that you can show vulnerability without it being a weakness or being seen as a weakness and that for me is lovely.'(Participant 3)