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BABCP Response - NICE Consultation January 2022

‘Don’t Worry About Exactly What Is Wrong, Just Throw Everything At It’ 

 

This is the rule of thumb operated by Service Providers of psychological therapy. Evidence-based assessment has been thrown out of the window. It is buttressed by a belief that diagnostic labels are particularly inappropriate, nay dangerous.  The results are graphically illustrated by this example:

Recently I encountered a 16 year old who had had variously CBT, Dialectical Behaviour Therapy, EMDR and antidepressants over a 3 year period. He w.as put on this trajectory by a clinician who had the impression  that he had generalised anxiety disorder and made mention of some OCD symptoms. But there was no definitive diagnosis. Part way through this period he began to self-harm. At my assessment, conducted with a standardised diagnostic interview, I found that he was self-harming, had generalised anxiety disorder, social anxiety disorder and panic disorder. I searched in vain in the records for any evidence that there had been fidelity to an evidence based protocol for any of these disorders. The nearest I came was discovering from him that he had been invited to distract himself when he had the urge to self-harm. Fortunately the case has not progressed to suicidal behaviour. But it is perfectly possible to imagine such a person might commit suicide. Suppose then the family decided to sue the Service Providers, how would that work out in Court?

How could the Defendant’s convince a jury that they were not a law unto themselves? The Defendants might rightfully claim that their modus operandi was no different to that of other Service providers. Leaving the jury to muse ‘so they are all crap, then?’.

The Judge is likely to be unimpressed by the Defendant’s Expert Witness claiming that the Service providers approach is evidence-based  when no definitive diagnosis has been made, much less the following of a treatment protocol dictated   by the diagnosis.  The Judge acts a a protector of the jury against ‘junk science’, probably even more  so in the United States legal system. She/he will be at a loss to understand the claims of  the Defendant’s Expert and the Service Providers clinicians that their approach is evidence-based.

The Defendant’s Expert might rail that that vast clinical experience is all that is required for effective treatment. Silenced by the prosecuting barrister’s question ‘did it work in this case?’. Following a deafening silence, the prosecuting barrister asks ‘why was EMDR used to treat him, when there was no evidence that he had PTSD?’. To which the Defendant’s barristers retorts ‘it just might have worked’. Moving on to the self-injury and suicide the treating therapists are asked ‘in training were you taught how to identify the thoughts and behaviours behind injury/suicidal behaviour?’ and ‘were you taught how to modify them?’ . The therapist likely replies ‘no but I went on a workshop for DBT post qualification’.  The prosecuting barrister persists ‘were is the evidence that you tackled the thoughts/behaviours behind self-injurious behaviour?’ 

The Judge may well conclude that the Service Providers have let down this teenager by allowing ‘junk science’ to rule, resulting in his following a horrendous trajectory that was reasonably foreseeable. As such they are legally liable.

On Appeal the Service Providers may protest that diagnosis is overrated. But the Appeal Judge comments that the Improving Access to Psychological Therapies claims NICE compliance and the protocols advocated by the latter are largely diagnosis based.  Further the IAPT’s Manual states that its’ clinicians don’t make diagnosis. The Judge opines that this has the smell of deliberate misrepresentation to secure the Government £2 billion a year funding and that the matter should go to the Crown Prosecution Service that deals with criminal matters.

There are those who are avowedly anti-diagnosis but this is much less credible when it comes to depression and the anxiety disorders. Albeit, that a more credible case can be made with regards to ADHD, ASD and Psychosis. With regards to depression and the anxiety disorders (the supposed mainstay of IAPT) the levels of inter-rater reliability using standardised diagnostic interviews have been found to range from very good to excellent [ e.g Tolin et al (2018]. This contrasts with reliabilities of no better than chance when the customary open ended interviews alone are used. The burden of proof is on those who oppose diagnosis to demonstrate reliability of assessment and efficacy of outcome. The case above graphically demonstrates the outcome of unbridled clinical judgements. Psychological therapy has to grow up and address the issue of accountability. 

The case presented above is not exceptional, in a sample of Australian psychologists only 11%  of those working with children or adolescents conducted an evidence-based assessment (the comparable figure for those working with adults was 21%) Moses et al (2020).

Dr Mike Scott

 

 

10 replies on “‘Don’t Worry About Exactly What Is Wrong, Just Throw Everything At It’ ”

I have tried to make case for my misdiagnosis on several counts including physical. They need to listen to their patients. I’m working class , my dad has be become complicated by my physical disability housing and rand port needs . They have been warehousing me. I’m in the UK. I feel they are deliberately doing the opposite what an autistic needs. No one will take the case on as they are resting me as housing, social services , MH, Autism, welfare, GP. But not as a whole human, I need support to access support. And one service won’t give service til I get a bungalow which they managed to screw up after 3 years on waiting lists . As they won’t own their misdiagnosis of my autism and likely adhd , they are all protecting each other, it has lead me to crisis who snd me in circles , the so called fake equalities commission who refer me back to the people doing it. They also miss diagnosed my spinal condition 8 years colluded with the DWP to relabel my diagnosis to deny me welfare. They twice experimented on me. Invalidated all my bullying and sex abuse snd trauma and gaslit me labelling me aggressive. They thought it was fair to “ deliberately aggravate the lady to elicit psychosis and “ I tried to elicit psychotic symptoms but it didn’t work she got sngry and I had to close the session” followed by I was greedy selfish and wanted more money than everyone else ( I’m a political activist that fights to help people often at my own cost) I know this cos I subject accessed a life time of my notes. They passed me around like a stinking steaming shit no one wanted to handle. They were effectively invalidating gaslighting and causing meltdowns not to mention leaving me in agony with my spine with 0 support. I was verbally apologised to by a lady who said they should of protected me as a child and that I have ptsd but I won’t accept services iff those that caused ths as they won’t apologise. I was diagnosed at 52. The my insured my last 17 years ( 23 treslky after burn out at work) was a living hell of insecurity pain invalidation misdiagnosis and they won’t listen to the effects of that and are just putting me on lists to warehouse me till the nhs collapses and gaslighting me. Supposed to be having a safe guarding meeting with an unspecified date but I honestly feel like they will slag me off and gang up on me then use my adhd and autism against me and deliberately trigger me. They protect their professions and refuse to learn from their mistakes. I had to demand to be present and even though I’m clear as day in speaking and intellect I have to get an advocate. They are saying I have to have one of theirs. Or they will make excuses about getting all the services and my chosen advocate together and will delay it. Essentially they are waiting for the nhs to collapse knowing I don’t have funds re court. ICA protected the drs too. Ombudsman leaves it all to me I have no physical advocacy it’s been an utter nightmare. As a result of part of my many complaints they have said they will mandatorily train clinical staff in autism and diagnosis . It doesn’t extend any where Newmarket far enough into Cahms. CBT well being practitioners or male mysogynistic drs who don’t think woman can be autistics . We are conveniently labelled repetitive behaviours and meticulous, by those with repetitive behaviours making all the error . I’m not a list of diagnostic labels I am a human being just like them and imperfect just like them and should be treated as a whole person not a list of failures and faults. That’s why MH in UK is failing. Their is a massive elephant n the room called socioeconomic status abuse bullying lack of security and poverty . When middle classes who have t known it are dealing with working class Autistics.

I think many clinicians working in IAPT would agree with you Mike. We have about 45 minutes to do an assessment which includes introductions, confidentiality, risk assessment, identifying treatment goals (which to me is ridiculous at the first phone call, people need time to think about their goals) plus quite often doing the MDS and ADSMs. As I’ve said it not uncommon for someone to come through the system 2 or 3 times with essentially the same symptoms but a different problem descriptor each time which is telling. I’m not blaming anyone, I am sure I have put an inaccurate problem descriptor on many, many times. It wouldn’t be accepted in physical healthcare.

CPTSD, among other things. No way would I get anywhere close to IAPT. This service is likely to be so destructive to so many .

Imho it is fascism in action by the right wing who were Infact what Nazis were . Instead of gas chambers it’s gas lighting victims. If people saw this autistics medical notes they would be horrified. Newcastles CNTW health authority and police is covering it up with me. Because they know I have my notes and they are avoiding letting me in a court room. Cos I’m on benefits as have other disabilities I have no means to fight back. Because the systems is protecting the privateering market. They don’t care about us, they care about cheap therapy they rip our nhs off with. I’m almost sure the nhs is deliberately targeting me now. CNTW needs shut down. They protect each other and continue the abuse of autistics they misdiagnosed and persecuted and wrongly judged and life long.

There is no ‘no definitive diagnosis’ in mental health work. The medial model should never have been exported from physical medicine and misapplied to mental health. Nor can we ever separate the mind from the body or either from the culture. People are experiencing a range of cultural disorders that cause a range of awful but natural, understandable and often preventable suffering. No one is living life in some sort of cultural bubble with all needs met and then suddenly bang they now have ‘depression’ or an ‘anxiety disorder’

People are being DE-PRESSED – pushed down and crushed by cultural disorders and we live in attention deficit hyperactive cultures, bi polar cultures and horribly de-pressing and anxiety provoking cultures – The mental health industry is in the business of internalising distress by disordering/pathologising the individual and turning them into customers for a range of ineffectual and often very harmful ‘treatment’s. In the process if helps to obfuscate these cultural disorders and helped to maintain the status quo – if the cultural disorders are mentioned at all its all reduced to a mere trigger – nothing to see in the world its all about your faulty, dysfunctional or disordered perceptions and behaviours. The mental health system itself is also profoundly bad for the wellbeing of its practitioners and is causing mass suffering nationwide and its worse in ‘secondary care’ Its an oversold, self interested mess.

Totally agree. Today I couldn’t attend my yearly medical , my hourly bus no showed. I tried to book a taxi, but no taxis available for 30 mins. I had another melt down contacted MP waiting to here from that, also was bullied by yhs so called sheltered housing as I had a meltdown there two after I heard the lady over the phone announce to he colleagues that I have a woman on the phone who thanks the world owes he a living. These are people working with disabled people who are clearly fascist prejudiced judgemental monsters. I’m a rat on a rat wheel spinning in circles and they want me dead. The authority. My authority , area is the one with the UK highest suicide stats 14.4% as opposed to Londons 6.6. The support system of charities services comprise of untrained middle class fare keepers crushing spirits and hopes and gaslighting us with be happy memes whilst the ableist disableist gatekeepers silence our voices, that is systemic right to the Onbudsmen, equality commission nice and CQC front doors. They refuse to listen or include patients or clients. We need help. I’m seriously looking at seeking asylum on disability discrimination and psychological T4grounds the grass is probably not greener on the other side. We are bought but gagged intellectually prisoners of a corporate fascist state that wants us to be slaves. Id like to talk with ECHR but I’m unabled to access it due to gate keepers at every level of the date and authority mechanisms. I want my day in court on all of it not bits of it. I’m a whole human being. At 53 I’m tired of fighting and proving myself to selfish cold face services. Google cold face people.

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