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BABCP Response - NICE Consultation January 2022

PWP’s Floundering – Problem Descriptors Are Unreliable

whilst they may describe to a greater or lesser extent the psycho-social context in which the client is operating, different therapist would disagree about the relative importance of the psychosocial stressors and have a different collection of them.  One may emphasise the clients current relationship another a harsh/ ? abusive childhood another poverty. 

At a recent workshop I gave a PWP (Psychological Wellbewing Practitioner)defended reliance on the use of problem descriptors on the basis that they could be complemented by the therapists intuition. But this was precisely the therapeutic task centred approach adopted by social work in the 1970’s, it failed to demonstrate effectiveness  and by the 1990’s social work had become confined to largely a policing role, replete to this day with meaningless checklists. I speak as a former social worker, consumer of social services for over three decades and as a psychologist.

With my psychologist hat on I am very aware of the the work of Daniel Kahneman on the use of rules of thumb (heuristics) in decision making, for example the use of the availability heuristic – the vividness of a description giving a mistaken impression of its’ likelihood, so that a therapist hearing the horrific details of a trauma assumes it must be PTSD. Loretta whom I saw recently simply had a specific phobia about driving/travelling as a passenger in a car as a result of very serious rta. Nevertheless the PWP directed her to a 6 week stabilisation group that did nothing at all for her  difficulties. But the stepping up procedure offered no protection, she attended 3 individual sessions in which she was asked to talk about and write about the trauma, she dropped out because she found the procedure too toxic.   Loretta’s difficulties in driving and travelling as a passenger were not addressed at all. I broke the good news that her problems could be simply addressed.

The PWPs were totally unaware that Beck’s first paper was on the unreliability of the standard interview. This led to the inclusion of standardised diagnostic interviews in CBT outcome studies. In my view the PWP training however quick and simple is not fit for purpose.

 

Dr Mike Scott

Ps Do listen to Radio 4 on Tuesday Sept 24th at 8.0pm  for its’ investigation into ‘The Therapy Business’

20 replies on “PWP’s Floundering – Problem Descriptors Are Unreliable”

Using therapist intuition doesn’t seem particularly evidence based but I think it is often what therapists use in the absence of anything else. When I started in iapt I think we were given a half hour talk on identifying a problem descriptor and that was it!

I know I’ve been guilty of hearing people describe a few associated symptoms and then jumping to conclusions about the problem descriptor without considering things like frequency or intensity and without really considering context. I’ve lost count of the number of people who come through for treatment of GAD who are going through an adverse life event eg redundancy and are (unsurprisingly) really worried about it.

Just 30 mins on problem descriptors in IAPT is appalling as it is claimed by the Service that these lead to the selection of the appropriate NICE protocol! Therapists are not equipped to distinguish lifes normal adjustment difficulties, to as u say redundancy, and treat everything, ‘might as well call it GAD’, the result is overload and mistreatment.
Hope the Radio 4 programme at 8.0pm tonight ‘The Therapy Business’ starts to put things right

Mike

Wow Mike, I clearly wonder what your gain is from your assumptions made about IAPT and posting them online are. Even though IAPT has it’s flaws I would totally disagree with you in many aspects from what you have shared on here and in essence you may well discourage people from seeking therapy that they need rather than promoting reaching out. From reading the context you have written I believe you don’t know what IAPT is about and the IAPT stepped model of care and the limitations and purpose it was set out to do and offer. You have taken the word of a patient of what they received prior to seeing you and then you go on to promise them that you will simply address her problems, which I would describe as unprofessional. You also attach your own bias and training of the pwp role and promote your own self importance that what you know is better than what every pwp knows.
From what I know is that different Pwps have different experience levels and when in treatment a pwp should continually assess a patients presentation and if the current treatment is helping or not, you have given an example of 1 patient and justified your own self importance rather than considering the bigger picture here. Sometimes there are many ways to help a person, a person may or may not be ready for different treatments, we assess needs, we use the psychosocial model and we use interventions to promote change and self efficacy, we have to start somewhere and that with considering the stepped care model focuses on providing the least intrusive intervention. I just want to ask you something, what would you work on if the patient didn’t want to work on the driving phobia as you call it, if they weren’t ready, would you have said no we can only work on what I think is the route cause? A person can say I have had depression, I have had anxiety “all my life”, but in fact they haven’t, they have had periods which they are clumping together because they are feeling the same way now as they did then, but giving a person the tools and techniques to understand this and to continue to help themselves should be a priority over self gain. I would also say that a lot of Pwps use thier own judgement/experience/problem descriptor and collaborate well with patient and appropriately challenge too to help promote change. I have treat psychologists, psychiatrists, nurses, teachers and social workers and from experience (15 years in IAPT) the simpilar the approach the better (as they can make it too academic or overthink it) but identifying the problem descriptor is a priority at the beginning to inform treatment, but then to continually assess is more important as things can change and treatment should be adaptive too.

From reading what you have suggested about the patient I would say they neither have trauma and they don’t have a driving phobia, I would probably think they have panic disorder, it would be interesting to understand the patients cognitions to the rta to gain more insight which then would inform the problem descriptor. I would probably say the pwp here (not all Pwps) might have been inexperienced but again that’s an assumption, the patient may have not fully told the pwp everything or shared with you everything, or the pwp may have been under service pressure for whatever reason to adhere to the stepped care model, or in fact the pwp could just have been incompetent but to suggest the pwp training and the IAPT services do not offer good treatment based on how well you do treatments is totally unjustified as you are comparing 2 skills set and job roles.

As I mentioned above IAPT does have it’s flaws but the Pwps I work with work relentlessly to provide good solid care to patients to improve their daily lives and I commend them for that, but they do have institutional limitations. It would be interesting for you to come and work as a pwp and see what it is like from the inside. You may have theoretical knowledge but I would question your own self importance and arrogance to what you have written. The training is not flawed (and it’s a damn hard course) and the training has provided the biggest change in providing free therapy for people rather than the rich who could only afford it previously, or is this change taking the money out of your pocket privately ?
I do also wonder why you were giving a talk to a pwp if you don’t see thier role as being worthy.

I think the main thing lost in psychology is the patient, a lot of professionals out there in higher positions think from Thier own agenda and what they gain from it, influence, role, position, money, statue etc, what we should be thinking is what is best for the patient, how do they learn best, what will give them the best outcome, what will improve thier lives,!! That’s what we shouldn’t lose focus on.

The CQC is mentioned on pages 63 and 64 of the IAPT Manual published last year, so I presume IAPT is accountable to the CQC, it is just that the latter has not discharged its’ duty to assess outcomes in this case.
regards
mike

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