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

 

“What’s The Odds Of Getting Back To My Old Self, With This Psychological Treatment?”

the response is likely to be a deafening silence, from those most likely encountered, a Psychological Wellbeing Practitioner (PWP) or a GP. Alternately, they may reply  ‘it’s complex’, leaving you bemused or patronised with a reply of ‘we don’t know until you try’. But the cancer sufferer and those close, would not tolerate being fobbed off about the likely success rate of a proposed oncology treatment. Further they would deem  it necessary for a face to face consultation, with a Consultant, for this question to be satisfactorily answered.

Contrast this  with the likely scenario in mental health, following a self-referral you would undergo a  20-30 minute telephone assessment by a Psychological Wellbeing Practitioner (PWP) [ from the Improving Access to Psychological Therapies (IAPT) programme]  the most junior member of staff.  Unfortunately their training totally precludes their being able to answer this question. The problem is that the PWP simply does not know the answer. His/her stock in trade is low intensity interventions such as guided self-help or computer assisted therapy, delivered in six or less sessions. The PWP’s training courses inform them that such interventions outperform usual treatment. More than that they do not know. Their ambition is usually to become a high intensity therapist delivering psychological therapy, over a much greater number of sessions.

The PWPs are unaware that the success of Cognitive Behaviour Therapy (CBT) in low intensity outcome studies has been gauged solely in terms of a metric called effect size. The (within subject) effect size is calculated by subtracting the post treatment mean of a sample from the pre treatment mean and dividing by the spread of the results (the pooled standard deviation). [Alternately if there has been a comparison group in the CBT studies the means that are subtracted, are the post treatment means of each group, again divided by the standard deviation, to yield a between subjects effect size].  Assuming that a between subjects effect size has been calculated all this tells one is the size of the difference between the two groups, it does not tell you whether everyone improved a little, or some greatly improved whilst some did very poorly. Thus the effect size gives no information  that can be passed onto a client that would give them a guide as to the likelihood of their recovery after low intensity  intervention.  

By contrast the psychological therapies to be delivered in high intensity IAPT, are supposed to be based on protocols approved by the National Institute of Clinical excellence. At first sight this is good news because many of these studies indicate the proportion of people who lost their diagnostic status as a result of psychological treatment i.e these studies were concerned with an end point and not just with whether there had been a response to treatment as indicated on some psychometric test. But IAPT has only ever relied entirely on psychometric test results. This exclusive focus on response by IAPT however lacks any validity because it is not known what the person was suffering from in the first place!. IAPT eskews diagnosis, there is a consistency in this  in that because they don’t do end points, they don’t do beginning points i.e they do not establish what the person is suffering from in the first place. It is not possible to substitute measures of response for categorical endpoints, the latter are determined independently using standardised diagnostic interviews. Matters are compounded further because IAPT uses no measure of treatment fidelity, thus it is totally unknown whether IAPT actually delivers an evidence supported treatment. 

 

Dr Mike Scott