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.

 

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