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BABCP Response - NICE Consultation January 2022

Misdiagnosis Equals Mistreatment – Why Then Does NHS Talking Therapies Eskew Diagnosis?

The NHS Talking Therapies Manual (2023), p24 indicates that reliable diagnosis is not part of a ‘good assessment’. Yet paradoxically, it states that clients with PTSD or social anxiety disorder should not be offered low intensity interventions first. This begs the question, of how a clinician would know, which level of stepped-care was appropriate without making a reliable diagnosis. Its’ clinicians apparently have magical insight, in that they can determine from the ‘presenting mental health problems’, the appropriate National Institute for Health and Care Excellence (NICE) protocol.  But NICE clearly states that its’ recommendations are predicated on a reliable diagnosis. NHS Talking Therapies attempt to force a square peg into a round hole is risible.

To give a further example of the Services misdiagnosis consider the following.The Service rejects referrals with a psychosis label. It does not stop long enough to carefully consider whether the label is misplaced. Mr X was a casualty of this –  a series of mental health professionals, over a period of 7 years, declared that he was a paranoid schizophrenic, each uncritically accepting the label applied by their contemporaries. NHS talking therapies declined to treat him. Finally, he was seen by a clinician who expressed his total bewilderment at the historical diagnosis, and concluded that he was suffering from obsessive-compulsive disorder, obsessive type. He successfully treated Mr X for the OCD using a standard protocol for obsessions. The Service engages in a game of ‘pass the bomb’ when it comes to certain labels.

NHS Talking Therapies has nothing in place to protect a person against the ‘slings and arrows’ of outrageous diagnoses. The de facto missive of the British Association for Behavioural and Cognitive Therapies (BABCP the CBT Lead Organisation) is to ‘suffer’ these ‘slings and arrows’, reliable diagnosis is not part of any of its approved training courses. There is no sense of ‘taking up arms’ against misdiagnosis, even though its’ former Presidents are well aware of the importance of diagnosis. Their overriding concern, is it appears, the wider dissemination of services. Which is perfectly laudable in itself. But any good has to be contextualised, it was perfectly right in the early twentieth century to seek to redistribute wealth, but not as in Stalinist Russia, at the expense of reverence for the individual and honesty. It is difficult to escape the view that BABCP and for that matter, the British Psychological Society (BPS), are on a ‘mission’, that needs contextualising.

Dr Mike Scott

 

11 replies on “Misdiagnosis Equals Mistreatment – Why Then Does NHS Talking Therapies Eskew Diagnosis?”

It was the norm when I worked in IAPT for people to keep coming through the system with a different anxiety problem descriptor for each episode. It would be common for example for people to have been described as having panic when they first referred, then on the next referral their problem descriptor was illness anxiety, next referral generalised anxiety. It may be they had multiple problems but I think it’s far more likely these different labels were being used to describe the same set of symptoms. And the fact that they kept coming back suggests they were not getting better.

Perhaps NHS Talking Therapies should be termed ‘NHS England’s Diagnostic Lottery’ and in the pre-Christmas draw ,they have an ever expanding number of colourful labels, including ADHD and autism. In which treatments for the additional labels have proven inferior to treatments for those who have not merited the said labels.

There is only ever misdiagnosis in our reductionist ‘mental (ill) health’ systems, there is nothing else. Unless and until we have the same potential that exists in the rest of medicine but no one has ever seen a mind. Until we can identify a proximal cause via objective tests to determine a diagnosis we are stuck in subjectivity land. Get ten psychiatrists in a line and the same person will likely get a range of ‘diagnoses’ and even if they did manage some consistency between them, the disorders are cultural fictions.

Its worse than this because the DSM disorders have not been discovered in nature but are inventions that are voted into existence by committees of largely white middle class Americans. Many works, including Whitaker and Cosgrove’s Psychiatry under the influence demonstrate that the people involved in these committees are heavily influenced if not corrupted by drug companies. This is the business model in action – the broader and wider the ‘disorder’ definitions and criteria are made the more people with problems can be converted into patients on pills. We see the disastrous results all around us.

Every person and their dog are now self labelling and labelling just about anything that walks as disordered and in need of ‘treatment’ We are losing the ability to describe our natural variation and reactions to a range of cultural disorders in anything but medicalised language. You are advocating that this dead and harmful paradigm is extended and I personally cannot think of anything worse.

Thankfully things are changing at high levels but the corporate power and self interest driving this medicalised nightmare will take some stopping https://www.madinamerica.com/2023/11/the-new-who-and-un-guidance-psychiatry-must-entirely-change/

NHS talking therapies/ iapt is a worked example of what happens when reliable diagnosis is jettisoned. There is no empirical evidence of the delivery of effective psychological therapy without the use of diagnosis.
The randomised controlled trials of cbt for depression and the anxiety disorders offered the hope that using specific protocols, for particular disorders, it was possible to make a real-world difference to clients lives. But as IAPT highlights, there has been no faithful translation from the rcts to routine practise. You could take the view that the trials were meaningless, leaving you up a creek without a paddle. But then you have returned to therapy as it was before the 1970s a total lottery, ruled by ideologies.

I would be delighted to provide psychological therapy without the use of diagnosis if there was any evidence of its efficacy. You are caricaturing diagnosis, you don’t have to believe that the diagnostic labels are biological entities, they are simply constructs that have some utility, rather like agreeing to drive on one side of the road. Nor do you have to take a reductionist position. I quite definitely don’t, people have choices and the most important things like love and beauty are immeasurable. Unreliable diagnosis is a total disaster, just come across a case of a guy diagnosed with schizophrenia for 15 years, none of the clinicians had considered an alternative diagnosis, until one concluded that the better explanation was OCD and he was successfully treated with CBT. The guys protest was that previous clinicians had not taken the time to listen and carefully consider the differing possible diagnoses.The danger is that clinicians stop at the first condition they come across, and the label gets passed on as if its gospel and nobody bodies to think of the bigger picture including social factors.
Take care
Mike

Thank you Mike.

I don’t think we have left the lotto and ideological situation you mention.

Surely the medical model as misapplied to ‘mental (ill) health’ itself a meaningless reductionist concept, is ideological.

An ideology, that fits neatly in with and is thus supported by, the neoliberal status quo across the neoliberal parties. The issues are not cultural disorders that require political/economic change to make the world a better place for all but are really personal disorders and we must adjust our faulty perceptions and get on with it. What could be more ideological than that? No matter that destitution in one of the richest places on earth has doubled in the UK in the last 3 years, or most people hate and are harmed by the jobs they do decade after decade or can’t afford to turn the heating on and on and on.

There is no such thing as reliable diagnosis Mike, how can there be? What and where is a mind? How do you compare this fictitious entity one to another? As already mentioned the ‘disorders’ are not discovered but invented and are shaped by corporate power and the business model. So yes, why not throw away the studies adopting this failed paradigm? what might it make way for?

The case of the poor chap labelled with ‘schizophrenia’ for 15 years you mention, is surely evidence of this subjectivity and the unreliable nature of diagnosis?

If this person has spent 15 years in the system dealing with psychiatrists and therapists I’d be very supervised if he hasn’t been given multiple labels along with every drug in the book and multiple talk therapies.

Even if he is one of the very rare people stuck with one label just because someone else has said he has ‘ocd’ doesn’t make it so. Perhaps these experiences are prescribed drug related? perhaps he’s withdrawn from a drug, and we could go on perhapsing for infinity.

The idea he’s been ‘successfully treated’ after being given the OCD label and some CBT has to ignore the unfathomable complexity of any change process for human beings. We are built to tell simplified stories about what is but this does not and cannot map on to the complex nature of what is.

The cultural impact of diagnosis for most people is that people do believe they are real biological entities and not some helpful construct as you put it.

They act as a sort of a self fulfilling prophecy and we learn to become the label and so does everyone around us and then everything shifts. We are no longer a person with problems but a patient on pills or in therapy, usually both. Such a powerful identify no?

Just look at the deluge of people online self identifying with these labels, its is completely and dangerously out of control. There are so many people being labelled with ‘adhd’ there is a shortage of stimulant drugs.

If only people had choices but the ideology dominates so much so its part of our cultural furniture now. Just listen to the ways in which we all habitually use these medicalised terms in daily life.

We are losing the ability to describe and understand our experiences in any other way and are looking in the wrong place for what needs to change.

Informed choice/consent is almost completely missing from the mental health industry whether it be drugs or talk therapy. If people were given accurate information about both of these the placebo effect would be dismantled as would any perceived efficacy.

As others have pointed out the most important element in any successful therapy is nothing to do with therapy and is all about the individuals resources coming in for therapy. What we mean by successful is again subjective and cannot attend with the complexities of living human beings in context and the change process.

You have made a caricature of the medical model. The DSM is essentially multi-dimensinal , requiring consideration of social and biological factors, without a multi-axial classification those using diagnoses don’t know where they are going. There is no use in diagnosis per se only in reliable diagnosis. What you are really attacking and quite rightly, is the common practise of routine diagnosis. It is not a lock stock borrowing of the model used in medicine, but a borrowing of what is useful e.g assessment using blind assessors, fidelity to protocols. But also acknowledging what makes us human and different to machines. As a psychologist I have never treated anyone as if the totality of their experience can be reduced to biology.
I have no doubt that Society is not benign to mental health, it wasn’t when my ancestors left Kilkenny in Ireland in the Potato famine, with mass graves. Looking at the Middle East I am lost for words.
The chap who allegedly had schizophrenia for 15 years, was treated by people who failed to enquire systematically about the symptoms of schizophrenia and totally failed to acknowledge what evidence might disconfirm this, this was ‘fake’ diagnosis. Standardised diagnostic interviews require examination of competing hypotheses. He had indeed been given multiple drugs over the years but in the morass of his symptoms OCD was clearly visible.
In his case functioning like his partner post CBT treatment, constituted for him a real-world gain.
The notion of complexity has to be dealt with, with great caution. There is indeed something unfathomable about the choices people make e.g letting a different class of people just starve. It is also mysterious what stirs people. But complexity can become the great excuse for ‘crap’ treatment, it is currently pervasive in the PTSD area. Unfortunately people understandably take on board that they are a ‘complex’ case adding to their difficulties with therapists doing weird and wonderful things.
You are absolutely right about the perils of people self -identifying, recently saw a lady who 10 years ago was told she had Aspergers and that was why she had never benefitted from therapy. But I found she had learning difficulties, felt overwhelmed by words, needed pictures not explanations, very brief sessions each followed by simple text message and accompanying on her phone to do baby step dares.
You assert the that use of diagnosis is a product of economic forces but if I say that is not at all my motivation this will likely be dismissed. But it is being dismissed on a priori philosophical grounds and not because of evidence. It is a philosophical position to say all people have the resources to solve their own personal problems, but that is not at all demonstrable, albeit that it may be your article of faith. My lady with learning difficulties clearly did not have the resources to manage her fearfulness.
Although you repudiate reductionism, paradoxically that is what you let in by the back door, ‘there is nothing unless there is a biological test for it’.
Best wishes

Mike

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