Some thoughts on ‘Psychological Wellbeing Practitioners (PWPs) Ill-equipped, Yet On Sentry Duty’

I’ve been a quiet Mike Scott fan for a while. The stated aim on his blog site is ‘This site could be like a Field Hospital offering succour to all those in need but who are also protesting about the ‘war/failed system’. My hope is that many of the participants using the site will be like the ‘war poets’ telling what it is actually like at the ‘front’.’ I’m 100% on board with this ethos, it echoes my experience of working in IAPT and the wider mental health system and attempts to meet a need I was already aware of.

It’s refreshing and reassuring to see someone with ‘Dr.’ in front of their name ask IAPT challenging questions. It often feels like the things that don’t work well in IAPT are brushed under the carpet, with no platform for the issues to be examined and addressed. IAPT does not welcome challenge or change, as a rule. Dr Scott takes an angle that I am not equipped or qualified to take and there have been times when he has felt like a champion who was addressing systems that are far too powerful for me to take on. However I’ve noticed a trend of him taking aim at low intensity through his blog and after the latest article left me spluttering I wanted to respond. Where I’m coming from is an attitude that we should be held to a high standard, IAPT should be willing to examine its flaws and initiate change where change is indicated. Training programmes for Low Intensity therapists should encourage critical examination of the evidence base and careful consideration of the power inherent in their position within a broken system while working with vulnerable adults. Scorn levelled at the low intensity workforce though? No, I can’t let that go without comment.

As far as I can make out Dr Scott has never worked in an IAPT team and therefore has never worked alongside Low Intensity Therapists (LITs/PWPs). His writing does not indicate any understanding of the reality of low intensity work or the reality of the systems that we work within. He completed a review in 2018 in his role as Expert Witness to the Courts entitled Improving Access to Psychological Therapies (IAPT) – The Need for Radical Reform . This article claims to discredit the assertion of IAPT recovery rates after an incomparable further assessment of only 90 former IAPT patients.  

Dr Scott does not compare like with like and he repeatedly insists that IAPT report recovery only on the PHQ-9 and GAD-7, ignoring the raft of anxiety disorder specific measures that we are trained to use when we suspect that they are indicated. No IAPT service or low intensity therapist claims to offer the same service that a patient would expect from a multi-disciplinary mental health team or clinical psychologist. We teach a 45 minute structured assessment model which is built around a five areas formulation and underpinned by the COM-B model for behaviour change. Some services refuse to allow more than 35 minutes for an assessment appointment, including collection of the IAPT Minimum dataset (which includes a Phobia Scale and Work and Social Adjustment Scale which should be used in collaboration with the patient to interpret the outcomes from the PHQ-9 and GAD-7). 

Dr Scott presents a case story in his post:

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…’

The low intensity assessment

The low intensity assessment is not a mental health assessment, it is an assessment of the impact of the symptoms most associated with depression and anxiety disorders and a consideration of how suitable an IAPT intervention might be for the person who wants help.

When James Spiers, a colleague and another Mike Scott fan, commented to me on this piece his response was ‘It’s a bad assessment, nothing to do with PWPs’. A bad appointment is something that we have all been guilty of. It’s horrible that it happens but psychological practitioners are human and subject to human fallibility. In a good service mistakes would be caught in supervision and we’d take learning from them. Measures would be in place to make sure that any adverse effect on the patient was apologised for and corrected quickly. This patient attended an IAPT assessment with symptoms that were not straightforward mild-moderate depression and anxiety. In a perfect world they would have been offered a few hours of assessment by a practitioner who was qualified and supervised adequately to provide diagnosis. The LIT is not that person and we are not allowed that kind of time.

In my experience I am usually in the opposite position to the therapist in this case study. Many times people have attended the assessment appointment having Googled their symptoms and they ask me to tell them if they have got a personality disorder, bi-polar, ADHD or psychosis. In those cases, when the goal is further assessment and diagnosis of a mental health condition that is not depression or anxiety, I have to explain that I can’t provide what they want and they should ask their GP to refer to the community mental health team if the GP agrees this is indicated. There is literally nothing else that we can do there. IAPT teams are usually not part of the community mental health team so they can’t reasonably be expected to provide information on waiting times in other services.

Worn out Gate Guards

‘PWPs are simply not equipped for the purpose of guarding entry into the mental health services’ I couldn’t agree more strongly with this statement. My response would not be to write off a profession that does incalculable good in primary care though, I’d be asking why we aren’t building a robust system that doesn’t put low intensity in the position of gatekeeper to mental health care. It’s a perversion of the role and what the role can achieve, and an abuse of low intensity therapists.

The post on CBT watch states ‘nor is there any credible evidence that they [LITs] deliver evidence based treatment.’ Take into account that low intensity therapies are an infant modality and the rate of progress in developing structures around the profession is astounding. There have been developments in assessing the effectiveness in LI work. This includes competency measures for low intensity practice that were published in Behaviour Therapy earlier this year. The competency manuals and scales give us a way to measure not just that PWPs include the correct elements in their work but how well they do it. Of all of the Psychological professions the manualised low intensity CBT interventions are most closely mapped to NICE guidelines and the best available evidence. They are implemented by a skilled and agile workforce who work under immense pressure and heavy responsibility while often suffering personal harm for doing so.

Time to talk?

Obviously I can only give a perspective from inside the IAPT system. From a certain angle you could argue that I’ve been brainwashed into compliance with the low intensity model and method and I wouldn’t have a problem with that. The observations offered by people like Dr Scott from outside are a vital perspective. I would welcome observations from such outside observers about what it is they think the low intensity workforce should know and do differently, and how this fits with the current commissioning and targets that IAPT services operate within. Is there any way to open a constructive dialogue? Maybe it would be helpful to develop an ‘anti-IAPT’ reading list, what are the key references that will highlight the weaknesses in the IAPT programme so that we can address them? Can we get a dialogue going somewhere far above my head that leads to real change on the ground so that John can get the support that he needs quickly?