Mental Health Triage Practitioners Don’t Know Who Is Suffering from What, or What Needs To Be Done

The Government’s Improving Access to Psychological Therapies (IAPT) programme has decided to experiment with enabling the public to directly book an appointment with a Psychological Wellbeing Practitioner (PWP). But IAPT and the Government are keeping quiet, that PWP’s are not trained in making diagnoses nor in providing psychological [ IAPT Manual (2019)]. They have made it impossible for the public to give informed consent. The public are being conned. In the interest of ‘efficiency’, IAPT is by-passing managerial and admin staff. 

For the most part PWPs have nursing or social work backgrounds with a first degree. A recent patient of mine could easily have made direct access to a PWP, I shudder to think what they would have made of his abrupt mood changes, sometimes changed image as he looks in the mirror and periodic disengagement from life. Though not abused himself as a child, he witnessed parental abuse. To put it bluntly they wouldn’t have a clue what was wrong, much less what to do about it. What then is the unique body of knowledge of PWPs?

Given that successive Governments have never conducted an independent audit of IAPT since its inception in 2008, who can say that the billions of £’s service, is value for money? It is to be expected that a service itself will claim itself essential, and in support of this IAPT claims a 50% recovery rate [IAPT Manual (2019)]. But my own independent study Scott (2018) suggests that only the tip of the iceberg recover. As far as mental health is concerned there is no evidence that those  availing themselves of IAPT fare any better than if they had attended the Citizen’s Advice Bureaux. But the CABx is upfront with no pretence at having mental health expertise.  Is the Government running a production line or endeavouring to improve mental health? No answer from the Health Secretary yet.

Dr Mike Scott

 

A Psychological Wellbeing Practitioner Breaks The Wall of Silence

 

I will never forget how, when I started working at the IAPT call-centre, I was stressed and rested my head for a few moments. I was interrupted by a “clinical psychologist” who in accusatory tone proclaimed that, “it does not seem that you are working”. The die it seems was cast. Not once in my 3 years as a Psychological Wellbeing Practitioner (PWP) have I felt that anyone at work cared for one another.

 

 

‘When I Want Your Opinion I’ll Give It To You’

 

Naively I thought that “psychological services” would be a haven of openness, not a venue as “hellish” as any other sales related job. Contentious issues were not allowed to be placed on the agenda at meetings. If I dared to bring up issues that mattered, the Managers would “have a word with me in private”. It felt like “The Twilight Zone” and “Twin Peaks”; you could feel something was not right, but everyone pretended that things were fine and that it was me who was the problem. If there was any issue with what I said, no one gently told me, instead they went straight to my manager. So, I always felt paranoid that whatever I say or do, may be reported.

I will never forget the moments where I would try to bring up a new approach or new knowledge only to be told “it is not in line with NICE and IAPT” and “do not read extra information because you will not need it”. A re-enactment of George Orwell’s 1984, rather than the delivery of a 21st Century psychological service. Worryingly this seems to be the norm in the NHS, with the frontline troops powerless. 

 

What It Is Really Like At The Coal Face

 

The short end of it all is that being a PWP is very similar to run of the mill call-centre, telemarking and sales job. No matter what the average worker says “but we do a great service”, I feel they are a tad bit delusional. I do not blame them. To survive this job you either need to resort to trickery or delude yourself that you are doing something worthwhile. The latter group probably have a mortgage to pay. We are told what to say, how to say it, when to say it and constantly told “it’s all about the numbers/targets”. We also have a script, which is very similar to those phone contract customer service people. The hellish brilliance of IAPT is that if the targets are not reached, the organisation uses an attributional bias to blame the “practitioners”/miners and not the “system”/pit owners and fellow travellers.

 

The Re-Branding of What Doesn’t Work, Doesn’t Work

 

Pre-IAPT there were “mental health workers (MHWs)”, and the public had some idea of the discharge of this particular, professional role. But from 2008 MHWs became Psychological Wellbeing Practitioners, leaving the public and professionals scratching their head as to what the designation might mean. Where PWPs to be regarded as professionals or not? Despite the inherent confusion, I followed my work’s advice to the letter: did the questionnaires, kept the original scores and ploughed onwards. However, what I noticed is that many clients (I dislike using the term patients because it doesn’t feel like we are official clinicians either) were finishing treatment or dropping out with “high scores”. It was not too long until I was interrogated for a below 50% recovery rate.

 

Jumping Through The Hoops of ‘Recovery’

 

The recovery rate of 50% is impossible unless one manipulates the numbers or manipulates the clients to be compliant. I guess, good old fashioned “sales tactics” (convincing people they need a product or that they are better than when they started). Of course, the Managers did not care. Safe to say, I found a crack in the system: since the powers all care about numbers, if you deliver the numbers, they will not question you. However, dare you dip below what is expected of their Key Performance Indicators (KPIs), then they are like bloodhounds searching for you. But there has never been a real world KPI that a client would recognise, such as being back to their old selves for at least 8 weeks after treatment. Instead clients are expected at each session to doodle on questionnaires in the prescence of the PWP and bizarrely, these are used as the metrics of recovery.

 

At the coal face, I can conceal, to a limited extent what I am doing from the powers that be and deliver something of benefit. I do not hound them for the questionnaires every single time because let us face it, that creates a major barrier in treatment. Also, we are not MDs or Clinical Psychologists that can diagnose. It is a joke when we have to collect the data because it is meaningless.

 

Helplessness

 

The issue then becomes that I did not feel like I was learning anything. All I was learning was how to manage office politics and be a better liar. One could apply for High Intensity Training but they still focus on targets, so, no thanks. Any person of good conscience will not last long in IAPT. If you have any issues as a worker with IAPT, they will say it is a “you” problem. I once mistakenly vented my frustrations with how they were doing things at a meeting. This resulted in evident displeasure and near the end the next meeting was told to “this is not a space to vent grievances”. If the clients and workers had a platform to vent their frustrations, I do not think IAPT would still be operational. 

 

PWPs Ambassadors For A ‘Failed State’?

 

Working in IAPT is robotic: clicking tabs, ticking boxes and collecting numbers – a                                de-humanising experience.  There is little to encourage anyone to become a PWP. In fairness I suppose, at least a personal level, I have survived lockdown financially. But the service has in effect been “cooking the books” and making the company look good. I fear for the mental health not only of the ambassadors but for that of clients past and to come.

 

I am off to other pastures, can you wonder at the turnover?

 

Bernice ( a pseudonym)

 

 

Low Intensity CBT, ‘Penny Wise & £ Foolish’

Psychological Wellbeing Practitioners (PWPs) deliver the smallest dose of psychological interventions (low intensity CBT), less than 6 hours of contact per client (Shafran 2021). Making it cheaper than high intensity CBT. But there is little evidence that the PWPs ministrations make a difference the client would recognise. There are no randomised controlled trials of high or moderate quality (Cochrane Grade) that attest to low intensity CBTs efficacy. The PWPs are not psychological therapists, as such, most IAPT clients do not receive psychological therapy. The name IAPT, Improving Access to Psychological Therapies is therefore an example of doublethink. Here we have a classic example of false economy.

Low intensity CBT is intended to be the first step for those suffering from depression and the anxiety disorders, with PTSD and OCD clients going straight to high intensity interventions. Most clients first encounter low intensity CBT, should they not respond they are placed on a waiting list for high intensity CBT. In practice comparatively few, about 10%, are stepped up,  but with wide regional variations.It is not so much stepped care as stopped care.

Implementation of the ‘stepped care’ model costs the taxpayer of over a £1bn a year. But there has been no independent evaluation of the package or its components. IAPT is the first ANGO (an autonomous non- governmental agency) funded by the government, as opposed to the intended and understood QUANGO – a quasi autonomous non-governmental agency. Perhaps the National Audit Office and MPs might care to explain why there has been this failure of governance?

 

Dr Mike Scott

What Treatment by Psychological Wellbeing Practitioners (PWPs) Works for Whom?

 

This is a restatement of the question asked by Roth and Fonagy in their seminal work ‘What Works for Whom’ (2005) Guilford Press. This text formed the backbone for the National Institute for Health and Clinical Care Excellence (NICE) recommendations on psychological therapy. The Improving Access to Psychological Therapy (IAPT) service has made a formal commitment to observe the NICE guidelines. PWPs are the most common providers of psychological interventions in IAPT. They have been operational for over a decade, at a cost of £billions, answering this question with regards to this professional group is therefore long overdue.

PWPs Modus Operandi

The BABCP ‘PWP Registration and Renewal Policy’ under a heading ‘Core Principles’ states

‘PWPs are specially trained to work with people who have common mental health problems such as anxiety disorders and depression, to support them in managing their recovery…….are revolutionising our approach to the delivery of psychological therapies in a number of specialist areas…..Have graduated from a British Psychological Society (BPS) Accredited PWP training course/apprenticeship’.

PWPs deliver low intensity CBT, defined by Shafran et al (2021) https://doi.org/10.1016/j.brat.2021.103803  as offering 6 hours or less client contact. The input can be any self-help material. This is a ‘revolution’ in that it is substantially less dose of therapy to that in the high intensity CBT prescribed in the randomised controlled trials of CBT for depression and the anxiety disorders, with 10-20 sessions being the norm.

IAPT’s Magical Beliefs Include:

‘ Six hours or less clien’t contact makes a real world difference to client’s lives’ and ‘inputting any self-help material will do the job’. But what is the evidence for these beliefs? At the advent of IAPT Lars-Goran Ost (2008) published a set of key questions (see the end of this blog) that researchers had to satisfactorily answer for a treatment to be considered an Empirically Supported Treatment (EST). No judge would declare that these injunctions/criteria have been comprehensively answered in any of the low intensity CBT studies. It follows that low intensity CBT is not an EST.

The Government and IAPT

The Government’s wish to push ahead with low intensity CBT parallels Priti Patel’s insistence that refugees are sent to Rwanda, over the heads of Civil Servants who claim that it should be first demonstrated that this makes economic sense. Once the powerholders decide on a course of action, they are unrestrained by any moral imperatives to show compassion and hospitality. It is immoral to offer a dose of treatment for which there is no evidence that it works and to treat refugees so despicably.

 

Dr Mike Scott

 

L.-G. O ̈st / Behaviour Research and Therapy 46 (2008) 296–321

 

  1. Do not use WLC as the control condition, since criterion I requires a placebo or another treatment.
  2. Do not use TAU as the control condition, since the methodological problems described above are so extensive.
  3. Use an active treatment as comparison, preferably one that has been established as effective for the disorder in question.
  4. Do a proper power analysis before the start of the study and adjust the cell size for the attrition that may occur.
  5. Use a representative sample of patients, diagnose them using suitable instruments in the hands of trained interviewers, and test the diagnostic reliability.
  6. Let an independent researcher or agency use an unobjectionable randomization procedure, and conceal the outcome of it from all persons involved in the study.
  7. Use reliable and valid outcome measures; both the ones that are specific to the disorder and general ones.
  8. Use blind assessors and evaluate their blindness regarding treatment condition of the patients they assess.
  9. Train the assessors properly and measure inter-rater reliability on the data collected throughout the study (not just during training).
  10. Use three or more properly trained therapists and randomize patients to therapist to enable an analysis of possible therapist effect on the outcome.
  11. Include at least a 1-year follow-up in the study and assess any nonprotocol treatments that the patients may have obtained during the follow-up period.
  12. Audio- or videotape all therapy sessions. Randomly select 20% of these and let independent experts rate adherence to treatment manual and therapist competence.
  13. Insert procedures to control for concomitant treatments that patients in the study may obtain simultaneously as the protocol treatment.
  14. Describe the attrition, do a drop-out analysis and include all randomized subjects in an intent-to-treat analysis.
  15. Assess clinical significance of the improvement of the primary measures.

 

A Psychological Wellbeing Practitioner’s Damning Indictment of Her Role

Last week a PWP (Psychological Wellbeing Practitioner) ALIEE November 25th 2020 put a post on this blog, calling for Panorama to take note of the desperate plight of PWPs – the main providers of services in the Improving Access to Psychological Therapies (IAPT) Service. Unfortunately the track record of the media in this regard is not good. It is a year since Radio 4 chose to broadcast predominantly the voices of  lead figures in IAPT and well known fellow travellers, rather than give expression to those at the coalface  and their clients.   One wonders what it takes for the media to wake up and ‘smell the coffee’ – £4billion has been spent on IAPT over the last decade all without any independent audit. Given the current, parlous state of Government finances this should at least come under independent critical review, perhaps by the Office for Budget Responsibility.

When a PWP candidly admits “I am trained to overlook the full picture”, it raises eyebrows. Then when ALIEE goes on to say that she operates purely with the ‘5 area model’,  this is jaw dropping.  This is not a model for any psychological disorder, by itself it is a heuristic for providing generic cbt, which has never been considered an evidence-supported treatment. Then this PWP states if clients still have high PHQ9 and GAD7 scores by the 4th session, it is the client who should be interrogated for their  competence in scoring, with the threat that if such scores persist there is the spectre of criticism from superiors. This is tantamount to fiddling results. It is atrocious that AIEE has been placed in this invidious position. I do not believe she is weak but rather like a prisoner at Auschwitz charged with the removal of dead bodies from a gas chamber.

The burden of proof is with IAPT to demonstrate that it has procedures in place to make it impossible for ALIEE to have been operating in this way. Protestations that ‘there a few bad apples’ in every workforce simply won’t wash.

Getting the media and politicians to listen is like getting the post war German Government to take action against war criminals. Action was only finally taken following many years of work by children of Holocaust victims. Unfortunately in the short term the implicit plea is that ‘we have enough to do with the Pandemic and Brexit, not to say Climate Change’ but the climate of the upcoming generation is affected by the mental health of today’s adults. 

Dr Mike Scott