John, a client of mine, had a telephone assessment by a PWP at the IAPT (Improving Access to Psychological Therapies) Service and was told that he might have bipolar disorder. IAPT referred him to Secondary care but without any indication of how long he would have to wait for an appointment, nor any indication of the possible consequences. Within minutes of talking to him it was apparent that he had never had an elevation of mood that lasted more than a day. Albeit, that on his best days he felt he could do anything, but others had never reported that his behaviour was strange or bizarre at those times. John did get low but not most of the day, most days.
The PWP hadn’t picked up at all that he was troubled by obsessive thoughts of engaging in embarrassing behaviour. John in fact had OCD but without overt ritualistic behaviour. It takes little imagination to realise that a client is likely to Google any suggestion that comes from clinician, making it wholly unacceptable to hint at severe mental illness without due care and attention. PWPs are simply not equipped for the purpose of guarding entry into the mental health services. Nor is there any credible evidence that they deliver evidence based treatment.
Consider how PWPs operate, armed with the results of a PHQ9, they interpret a score of 10 or more as indicative of depression. As a result it is quite likely they will be placed on what they consider a suitable trajectory for a depressed client. But Zimmerman (2019) [Using the 9-item Patient Health Questionnaire to Screen for and Monitor Depression, JAMA, 322, 2125-2126] has pointed out that the instrument over diagnoses people as being in the severe depression category and misses people in the mild category. He cautions that the instrument is not diagnostic and should only be used in the context of a standardised semi-structured interview such as the SCID, measuring change. Both BABCP and the British Psychological Society have been enthusiastic backers of IAPT, but have taken no steps to ensure that PWPs are aware of the limitations of self-report measures. They bear the responsibility for the current mess – for their own reasons they have put dissemination of services ahead of everything else.
A study by Chris Williams (2018) Williams, C., McClay, C., Matthews, L., McConnachie, A., Haig, C., Walker, A., & Morrison, J. (2018). Community-based group guided self-help intervention for low mood and stress: Randomised controlled trial. The British Journal of Psychiatry, 212(2), 88-95. doi:10.1192/bjp.2017.1 shows the bizarre conclusions that can flow from reliance on the PHQ9. He and his colleagues recruited patients from the community with possible depression, with a mean PHQ9 score of 15.2 (and standard deviation of 5.4) thus over 80% (83.8%) of cases would have been regarded as depressed. But according to the MINI diagnostic interview none of those in the immediate treatment group met criteria for depression and only 4% of those in the delayed access had depression. Despite the colossal mismatch between the PHQ9 results and the MINI he and his colleagues concluded that ‘low intensity class based CBT delivered within a community setting is effective for reducing depression, anxiety and impaired social function’ . This highlights the weak to non-existent evidential base for low intensity cbt.
Dr Mike Scott
10 replies on “Psychological Wellbeing Practitioners (PWPs) Ill-equipped, Yet On Sentry Duty”
Misdiagnoses can be made by any professional in mental health services.
I’ve seen psychotic patients sent to IAPT by CMHTs, patients with early dementia given the all clear by memory clinics, etc etc.
PWPs generally do a very good job of assessing a range of people in quite limited time. And they are usually well supervised.
Research shows PWPs are much better than CBT therapists at placing people on the right step in the stepped-care model.
I’m sure you are right PWPs assessments are likely to be as accurate as CBT therapists.
Trouble is they are both using the type of open-ended interview that Beck st al in 1962 found to be unreliable for meaningful discussion between clinicians about appropriate treatment He pointed out that a for a reliable interview you have to cover all the symptoms of a disorder and have clear criteria about whether a symptom is present at a clinically significant level. The upshot was the inclusion of standardised semi structured interviews in all assessments were a psychological intervention/drug was being evaluated. This in turn led to diagnosis specific protocols for depression and the anxiety disorders. There can be no evidence-based treatment without evidence-based assessment (EBA). Unfortunately PWPS are not given the space by IAPT to conduct an EBA and clients are then, like John asked to travel along meaningless pathways.
I am a PWP and yes I am good at assessing patient suitability in a very very short span of time, because I am trained to disreagrd anything and everything but only what fits in my 5 area model. I am trained how to overlook the full picture and what they want to bring in. I am trained how to bring thier risk scores down to make them suitable for me as HI are busy. How to question thier self harm by providing alternative stratagies on the top of my head and just make them say yes for the sake of records. I am trained at challanging thier PHQ9 and GAD7 measures if they are not improving at 4th session and how to politically make them givem me some favours.
I am a very weak person doing this job for my survival but waiting for BBC Panorama for IAPT one day
I was so moved by this that I am writing a blog on it. I don’t think that you are a weak person at all just placed in an impossible situation. Hopefully blog will be ready by Monday but if there is anything u want to add in the meantime that would be great.
very best wishes
This isn’t parity for mental health, unless it’s a race to the bottom. Any diagnosis will do, so long as the treatment’s cheap?
I totally agree Liz,it reminds me of a TV comedy many years ago ‘Never Mind The Quality Feel The Width’!
Take good care
Really interesting blog ‘Some thoughts on ……’ https://notaguru.blog/2020/10/27/some-thoughts-on-psychological-wellbeing-practitioners-pwps-ill-equipped-yet-on-sentry-duty/ challenging my blog.
As a CBT therapist I dread to think of the errors of judgement and poor decisions I have made in my assessments, I can think of several examples where looking back I got it very wrong. In every service I’ve worked in the expectation is to get the entire assessment done in 30 – 45 minutes. That includes introductions, confidentiality, demographics, contact preferences, MDS and any ADSMs, actual assessment, feedback about how the person found the assessment, treatment decision. I don’t think it works and I think people in distress trying to access some help suffer the most.
I find the views within this article to be contemptuous and altogether pretty ignorant.
I agree that more detailed and person-centered assessments are needed within mental health services to ensure the client’s needs are accurately being assessed and for appropriate treatments to be offered. In an ideal world, this would be available – but unfortunately due to funding issues, targets from commissioners, and the way health services are run as a result, this often does not happen. It is really important to recognize that this is not the fault of any of the front line workers.
Placing the blame on low-intensity workers, as you have done in this article, is a cheap shot. It shifts the blame from the flawed system itself onto the front line workers, who work incredibly hard to support clients to the best of their ability within such a flawed system. Also, as outlined by some of the previous comments, it is not just low intensity workers who have to deal with these challenges and the pitfalls associated with them – high intensity therapists do, too. So do practitioners working in services outside of IAPT, such as secondary care mental health practitioners and General Practitioners. To sum up, the problem that you are describing is not specific to PWPs, or even to IAPT services, alone. Therefore, I find it concerning that your article is focused purely on low-intensity practitioners, seemingly without any awareness that the issue being discussed is actually relevant to a wide variety of healthcare roles.
I currently work as a PWP, and I am well aware of the limitations of the PHQ9 and GAD7 – as are the vast majority of my PWP (and other IAPT) colleagues. The limitations of these questionnaires were discussed and critiqued within my PWP training course, along with discussion around how we can support clients whose difficulties are not being picked up by these questionnaire results. Contrary to your assumption, many PWPs are well aware of the limitations of the questionnaires before they even start practicing as a PWP. Therefore, insinuating that PWPs aren’t aware of the limitations, and suggesting that they use them ‘blindly’ without any critical reflection, is foolish.
It may be useful for you to get some real life experience of working alongside PWPs, as this will hopefully widen your perspective.
An “ill equipped, yet on sentry duty” PWP.