Psychological Wellbeing Practitioners (PWPs) Ill-equipped, Yet On Sentry Duty

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

 

7 thoughts to “Psychological Wellbeing Practitioners (PWPs) Ill-equipped, Yet On Sentry Duty”

  1. 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.

    1. HI Michael
      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.

      Mike

  2. 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?

  3. 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.

Leave a Reply