Diagnostic error occurs when a diagnosis is missed, inaccurate, imprecise, or incomplete.1 Diagnostic stewardship reduces diagnostic error primarily by reducing misdiagnosis. NHS Talking Therapies use problem descriptors, as a surrogate for diagnosis, and on this basis choose an ICD-10 code, but nowhere else in the NHS operates like this. Neither the validity or reliability of ICD-10 codes, established by these means, has been established. It is no more reliable than establishing a code based on the way the wind is blowing. The purpose of such a charade is to give NHS Talking Therapies a spurious scientific legitimacy. It is akin to a candidate for a post over-selling themselves at interview. It is tempting in such circumstance to blame the ‘candidate’, but the real problem is the interviewing panel ( Integrated Care Boards, politicians) all with their own agendas. These include being seen to do something that is immediately credible to the public, such as increase access, shorten waiting times. Achieving these goals maintains their position.
NHS Talking Therapies engages in further posing when it claims its’ therapists intervention are NICE compliant. Given that the services clinicians do not make diagnosis and that the treatments recommended by NICE are largely diagnosis specific, this is logically impossible. But by clever marketing and a strenuous avoidance of independent evaluation, NHS Talking Therapies perpetuates the myth. This is coupled with a phobic avoidance of discussion in the public domain. Preference is given to internal networking meetings of ‘best practice’ in which the agenda is set by the power holders in NHS Talking Therapies. Lessons in this are on offer from all totalitarian states, the only ones that pay are the subjects/clients.
The totalitarians are unwittingly helped by those who totally eskew diagnosis. The latter ‘free spirits’ have no metric with which to invalidate the claims of the totalitarians. It becomes a free for all of assertion and counter assertion, with no methodology that might lead to agreement. The primacy given to an individual therapists subjective formulation of a client’s difficulties can be easily dismissed on the grounds that it is idiosyncratic. In such circumstances the therapist’s bottom line amounts to ‘I want my autonomy at all costs, any infringement is coercion, deserving of my righteous wrath’ and an ignoring of the bigger picture.
Dr Mike Scott
Dr Mike Scott
Dr Mike Scott
1. Balogh E, Miller BT, Ball J; Institute of Medicine. Improving Diagnosis in Health Care. National Academies Press; 2015.
5 replies on “Diagnostic Stewardship’s Abscence from NHS Talking Therapies”
These seriously harmed me and lead me to ptsd, they misdiagnosed me, “ I tried to elicit a psychotic response “ dr brogan and Another DR Scott, “I deliberately aggravated the patient to cause a psychotic response” they were causing me to have autism melt downs ( yes they completely missed my autism and adhd) they labelled me border borderline personality disorder they character assassinated me, they mistook wha is likely adhd as grumbling hypomania. They invalidated me and character assassinated me and disrespected me as a human they were vile and cruel and feeding us meds aka anti psychotics. They need outed and when I got my autism diagnosis through I rang them and they eventually admitted they were under diagnosing autism in woman. They need shut down. I think they were colluding with the DWP and character assassinating and invalidating me there too. I was denied pip 14 years as a result which lead to actual psychosis and vitamin iron deficiencies. These is killers they and Cahms lead to suicides. North east suicide went up to 14.4% wheres as Londons went up 6.6%. Ask yourself why. Nice and CQC are useless so is the Onbudsmen and ICA . They protect these snake oil CBT types. Appalling and people like me need justice and are unable to access it. Because the justice system for the poor is made up of , complaints to authority , ICA ( England) Onbudsmen , equalities commission just send us back to those that did it to us. This to me is a human rights issue both for access to real justice. They ruin lives and lead to deaths, no wi der 1 in 10 autistics commit suicide. Their own ignorance sexism and invalidation have lead me to rage and melt downs they then diagnosed as other stuff it wasn’t. It was pure evil what they did to me. We need help. I’m still not getting support and I’m still waiting on social services and housing to act. My life’s a ball ache as men would say. Currently ringing the chemist and gp because they keep mucking my meds up only been waiting an hour re my drs and chemist cuts the phone off before we speak , they didn’t deliver my meds. No wonder I have arrhythmia 103 pulse at rest . Ringing my dr to go back to weekly delivered meds as when I do it monthly they do t fo it properly ( not because of me but because of them)
Dr Scott, assuming you meant “eschew”, I’m afraid I disagree with your characterisation of those critical of mental health diagnosis as “free spirits”. The invented citation (“I want my autonomy at all costs, any infringement is coercion …”) appears to be pure fantasy on the part of the author. This straw-man attitude is not – and never has been – part of any debate about diagnosis. The aim of diagnostic critics is emphatically not personal autonomy as practitioners but to support the autonomy of *each person seeking help* to have their story understood from their own perspective. Each time a person has their real story silenced by a pathology story where some kind of bogus defect is placed within the individual, they are alienated and abandoned a little more. Rather than aspiring to be “free spirits”, diagnostic critics point out that no mental health diagnosis has scientific validity and that we need another way to understand people’s pain and distress. The fanciful disorders contained within the diagnostic guides are at present unknown to any objective science. The idea that we need a scientific understanding of distress, even an “alternative” scientific understanding, is pure nonsense, a hangover from Taylorist attitudes, better suited to a McDonald’s kitchen than a clinic. We need human ways, relational ways to understand distress. We need to respond to hurting people not with manuals and ever more harmful and invasive technologies, but with warm humanity. The notion that these human qualities and skills could be all that is needed to help someone heal from harm seems to threaten all manner of guild interests. The term “free for all” is rather telling: for a would-be gatekeeper, nothing is more terrifying than a level playing field.
Hi Richard, I have a number of concerns about your post:
1. Your notion of ‘objective evidence’. You appear to equate the latter with the results of a biological test. Given that there are no diagnostic tests for any of the mental disorder, it follows that discussion of the latter is meaningless.
2. But there is nothing in science that can demonstrate that science exhausts everything there is, for example it has nothing to say about the law of contracts, the Roman Empire, morals, values, meaning, indeed what makes us human. It is therefore perfectly legitimate to go outside lab tests. Sojourns into these other areas may be more or less useful.
3. In my view any psychological intervention that is not conducted with honesty, humour and reverence, including recognising the person’s autonomy, is doomed to failure and I have tried to express this in Personalising Trauma Treatment and hopefully in the 2nd Edition of the self-help book Moving on After Trauma that I am starting to write today.
4. There are serious dangers with your approach. I saw a guy who attended a Hillsborough Supporters Self-help group for 25 years with no improvement of his flashbacks/nightmares or marriage. He was not aware that there could be systematic help for these problems. I don’t doubt the value of social support but the evidence is that it is less potent than systematic help see Ehlers 2014.
5. I do not accept the binary of psychological help and warmth.
6. You appear not to have considered the legal implications of your approach it would mean that a person who had learning difficulties and had committed a crime would be treated in the same way as the criminal without learning difficulties (for which there is no biological test). Recently in Court I was cross examined by a barrister intent on dismissing a litigants claim for compensation because there was no ‘objective evidence’ he had PTSD. The Judge considered that there were significant impairments in functioning in a wide range of domains (as DSM-5-TR requires) since the trauma and he was appropriately compensated.
7. I can see nothing in your approach that would stop treatment being totally idiosyncratic, even if it could retain the essential human dimension. Inspection of my previous blog on ‘Piracy..’ shows the arbitrariness of routine treatment in NHS Talking Therapies.
Dr Mike Scott
“I have a number of concerns about your post” – Far from collegial, your phrasing is loaded with the very power dynamic you deny is in play. Nevertheless, let’s have a look at your 7-point rebuttal.
(1) This writing doesn’t actually parse, but you appear to be suggesting that criticism of diagnosis is invalid precisely because psychiatric disorder itself is invalid. That is some self-defeating (and somewhat jejune) logic, sir. If psychiatric diagnosis is invalid, so is the notion of misdiagnosis upon which your argument rests.
(2) You appear to be dismissing my (correct) claim that there is no scientific evidence for psychiatric disorders because of the inability of science itself to know its boundaries. That is the “aliens may exist” argument for psychiatric medication. Not good enough. You want to medicate something you better be able to show me an illness.
(3) Is a straw man – no one is suggesting a psychological intervention should *not* be conducted with honesty. Secondly, I see you have a proprietary product to sell. Now I understand. Everyone except you is dangerous (TM).
(4) You don’t know what my approach is. Nonetheless you make reference to “serious dangers” but can only back that up with one anecdote about a man who went for peer group support and didn’t find it helpful. Peer support is not what I offer as a qualified psychotherapist. Further, the personal and the systematic are not mutually exclusive, as long as we have the humility to adapt systems to the expressed needs of the individual, rather than suppressing the individual to suit a system.
(5) I do not accept the binary of psychological help and warmth either. These things are not opposed or mutually exclusive. I don’t see how this is relevant.
(6) I do not work to meet the business needs of litigators or insurers. I act for my clients, who express their agency in referring themselves directly: something you would deny them. You conflate “learning difficulties” with typical post traumatic experiences. Even so, in your example the claimant’s post-traumatic distress was recognised and validated by a judge without any need for a formal diagnosis, so you have argued against yourself.
(7) The contention that the response (you call it treatment) should *not* be personal to the person receiving it is wholly flawed. It is precisely the opposite position – that treatment should be systematic regardless of the person – that is unhelpful, as in this case the clinician ignores the evidence of the person in front of them. We must respond to the person and act for the person.
The current Talking Therapies service is clearly flawed, but “misdiagnosis” is a red herring. Non-pathologising, non-proprietary trauma-informed practice that meets the individual’s need is not just a viable alternative but an imperative.
Richard to take your points in turn:
1. I agree with you discussion of diagnosis or misdiagnosis is meaningless in mental health if a lab test is deemed necessary to signify ‘objective evidence’.
2. In this blog or any other I wasn’t arguing a case for or against medication.
3. Your statement ‘Secondly, I see you have a proprietary product to sell. Now I understand. Everyone except you is dangerous (TM).’is an arbitrary inference, it implies you know my motivation better than I. This is incredibly patronising. It is more respectful to assume others innocent unless you have incontrovertible evidence to the contrary. I have never ever said that everyone except me is dangerous.
4. Please furnish from my writings were I have suppressed an individual to suit a system
5. I am making the point that it is possible to conduct psychological therapy in the manner I have written about whilst retaining all humanity.
6. In the case in question I made a formal diagnosis of PTSD for the Court and the litigant was compensated. You appear not to appreciate that an Expert Witness only has a duty to the Court and not to those instructing or the Insurance Companies. In suggesting that I did otherwise you are casting a slur.
7. The very title of my recent book Personalising Trauma Treatment, reflects the personalisation of treatment, it is exactly the responding to the person that you advocate.
Please point out were I have ignored the evidence of the client in front of me. Where is the empirical evidence that your ‘ non-proprietary trauma informed practice’ makes a real-world difference.