‘Just Give Us The Resources To Treat Personality Disorders’ and then what?

There has been a great clamour this week from mental health bodies, including the Royal College of Psychiatrists (RCP) for more monies  to address the grave problems of clients with personality disorders (PDs). But they have neglected to add that there are few randomised controlled trials of psychological treatments for PDs and those that have been conducted have had very different outcome measures. It is important that clients with personality disorder are given realistic expectations of treatment and are protected from commonplace misdiagnosis.

One of my clients lost access to her children in part because a psychiatrist claimed she had an emotional unstable personality disorder (EUPD), fortunately legal action is being taken against the local authority for their part in this debacle. The latter were insistent she attend a mentalisation group, my protest that she did not have a personality disorder and therefore did not have to  attend went unheard! The stresses of taking the legal action have been colossal. Maybe the energies of the RCP might be better spent making sure its’ members make reliable diagnosis.  As part of the legal proceedings in this case a Psychiatric Expert Witness rejected the opinion of the treating psychiatrist but not before a great deal of distress had already been caused to her and her 3 children.

Dr Mike Scott

Prestigous Journals Have Stopped Looking at Real World Mental Health Outcomes

Papers in Journals such as The Lancet, Behaviour Research and Therapy and Behavioural and Cognitive Psychotherapy have in recent years relied entirely on psychometric tests completed by clients, with no independent assessment by an outside body using a ‘gold standard’ diagnostic interview. The sole use of psychometric tests is great for academic clinicians, research papers can be produced at  pace and at little cost, securing places in academia. Conferences are dominated by their offerings but actually nothing is changing in the real world of clients.



The Lancet paper on the PACE trial on CBT  for chronic fatigue syndrome [Sharpe et al (2015) Rehabilitative treatments for chronic fatigue syndrome Lancet Psychiatry, 2, 1067-1074] provides a great example of how to ‘muddy the waters’. The authors presented CBT as making a major contribution to the treatment of CFS. But Bakanuria (2017) [ Chronic fatigue syndrome prevalence is grossly overestimated using Oxford criteria compared to Centers for Disease Control (Fukuda) criteria in a U.S population study. Fatigue: Biomedicine, Health and Behavior, ps 1-15] has pointed out that the authors used the very loose Oxford criteria for CFS, requiring mild fatigue, but the incidence of CFS is ten times less if the Center for Disease Control (CDC) rigorous criteria are used. Thus Sharpe et al had not demonstrated the efficacy of CBT in a population who truly had CFS. In December last the Lancet published a paper by Clark et al on predictors of outcome in IAPT but again the dependent variable is of  doubtful validity, changes on PHQ9 and GAD7 in a population whose  diagnostic status is unknown. In fairness in the discussion Clark et al (2017) do note that it is a limitation of their study that they have relied on self-report measures but there is no acknowledgement that their findings are actually unreliable. Doubtless their conclusion that organisational factors effect delivery of an efficacious treatment is true, but this is stating the obvious, if a treatment is found to be efficacious in a randomised controlled trial, unless there is a careful mapping of key elements in the rct e.g reliable diagnosis, ‘gold standard’ assessment, fidelity measures, there will be an inadequate translation from research into routine practice.

My hope for the New Year is objective measures of outcome so that we can truly begin serving clients, now there is a novel idea.

Dr Mike Scott

A Country called IAPT

Imagine you lived in a country where there was a pharmacy and a GP in every town but few hospitals. The pharmacy and GP’s services were widely advertised, encouraging all the unwell, or those who had not really thought of their symptoms before as illnesses to come in, get checked out and get treatment. The government set targets that a certain percentage of the population must be treated by the pharmacy and GP each year – if that target was not met the commissioners would be castigated by NHS England and an expensive tender process would be instigated, to bring “healthy competition“ to the market.

What if a GP and pharmacy were successful in advertising for all the patients and people turned up in their hundreds per month? You realise that you have not got enough supplies and enough staff to treat them all, so you “innovate” new methods, such as getting 12 patients at a time into the room and talking to them about what might be wrong rather than having time to check their individual symptoms. People with symptoms of diabetes were taught about diabetes, if the symptoms were there for another reason and didn’t resolve– what then? Maybe send them on another course and see if that sorted them out, maybe some internet self-help on diet or lifestyle would do – or, maybe they need to be checked out at hospital…..oh….there is no hospital, there was no money to concurrently expand the hospital, in fact, commissioners had saved money on the quiet by closing the hospital because there are no government targets for treating those outside of the GP and pharmacy. There are just a few hospitals further away with not enough capacity to see any more people whose piles may actually be bowel cancer or whose aches and pains are actually a degenerative rheumatoid arthritis.

As a patient who needed more than the GP and pharmacy can offer, you are confused and sad and angry -the GP and pharmacy advertised all over town saying – come and see us if you have these symptoms, but then you are told that there is nowhere to go if physio doesn’t fix that carpal tunnel and you need an operation, nowhere to go for the intravenous antibiotics for your severe infection where the standard course is not enough.

Imagine being a staff member at the pharmacy or GP – wanting to care for people and help them but having no time, having to break the bad news that, yes, there are recognised treatments for what you have but only at hospitals and we don’t have one of them, there is a private one but if you can’t pay you will go unwell and untreated. Might it seem to you that you need more staff to at least try and better help with the supplies that you do have? Oh, you discover that, although the government set guidelines for numbers to be seen, wait list times and recovery rates they set no guidelines for staff numbers and experience. So the commissioners have no basis to give you more budget for more staff and tell you rather to get on with the job or you will lose the service to another provider who magically can get the job done. Might you become stressed, depressed and less able to do your job?

This country is IAPT country. The country that demanded that its services for mild to moderate mental health conditions be built, with high targets to meet, with no proper staffing guidelines. The country that forgot to consider that expanding a mild to moderate service would attract the full spectrum of mental ill health. The country that once did the maths for how many therapists would be needed on the back of an envelope and then lost the envelope.

The country that forgot that not expanding but actually cutting your services for the more unwell would breed the cruelty of unattainable promises to the unwell, staff exhaustion and a desperation that leads to cooking the books to show that targets are met rather than standing up and saying that the Emperor of this country who proclaims that IAPT data is sound and targets are met has no clothes on.

A New Year Resolution – Take a First Step to Evidence Based Assessment

It is likely that for most agencies 80% of the work is in relation to a few disorders, (Pareto’s Law of the ‘Vital Few’) so developing an expertise  at identifying these accurately represents a good investment of time and effort.        First of all it is necessary to accurately audit what is coming in through you agency, this could involve using a screen for the 10 most common disorders, the First Step Questionnaire Revised ( available freely on this blog) and then  ask the further diagnostic questions in Simply Effective CBT  [ Scott (2009)] for any positive screen.  Knowing say the 4 commonest disorders dealt with by your agency it would be comparitively easy to cascade training for the accurate identification of these to front line staff, who have perhaps little training.   At a later date training can be given in say the next 4 most common disorders  and  so on so ultimately there is a comprehensive assessment.  Such rigorous assessment is also the best way of monitoring outcome.

Questionnaires completed by the client are subject to demand characteristics, clients wanting to please the therapist or convince themselves that they haven’t wasted time in attending therapy. Administration of weekly psychometric tests are particularly suspect, as clients can remember their scoring and show reductions which can be mistaken for real world differences.


Dr Mike Scott

Gifting Evidence Based Assessment

Evidence based assessment (EBA) is like unwrapping a Christmas present, the first layer is ‘What are we dealing  with (prediction)?, the next what are the options for use, ‘what can we do about it (prescription)? the core is whether the present has made a real world difference ‘ how will we know if we are accomplishing our goals (process)?


The three phase approach to EBA, prediction, prescription and process is described (minus the Christmas present!) in December’s Clinical Psychology Science and Practice by Youngstrom et al with an accompanying commentary (including the questions above) by Steven D Hollon.   Youngstrom et al suggest screening for the 10 disorders that most likely comprise 80% of your workload. This can be achieved using the First Step questionnaire from Simply Effective CBT, Scott (2009) London: Routledge an updated free version for 10 disorders is on this blog. Then using a standardised semi-structured interview for positive screens to reliably identify disorders.  Knowing the disorder/s it is possible to predict what is likely to be the best treatment, and prescribe appropriate treatment targets and matching strategies.  Assessment is not just a front end process, assessing whether there has been appropriate process can only be gauged at the end when the assessment is repeated to determine whether the client has got their life back.




In practice many therapists paddle their own canoe, if they stop long enough to really listen they would find that despite the client’s politeness, oftentimes scoring a psychometric test low to please the therapist (weekly administrations have also been found to artificially lower scores), there has not been the real world change.

A very Happy Christmas to Everyone


Dr Mike Scott

Heading Towards the Iceberg – The Mental Health Service’s Response to The Grenfell Fire

‘Three quarters of those living closest to the Grenfell Tower are suffering from PTSD, with 40% suffering in buildings a little further away’ (BBC Radio 4 December 14th 2017). But these figures from Grenfell Health and Wellbeing are highly improbable, numerous studies of responses to natural disasters show the incidence of PTSD is 30-40% amongst direct victims of disaster  and 5-10% in the general population [ Galea et al (2005)]. The rampant overdiagnosis of PTSD opens up the prospect of swathes people enduring trauma focussed CBT (or EMDR) quite unnecessarily. The spectre of inappropriate help rivals the sight of the Tower.

This gross overdiagnosis has come about because counsellors have gone door to door, ‘if they thought it appropriate’ the questions on a PTSD screening questionnaire  were asked and using a cut off a diagnosis of PTSD was made. This method on its’ own is highly unreliable, a screen has to be followed by a reliable standardised diagnostic interview  to establish true prevalence.

The interviewed clinician claimed that their approach was a ‘first’, but actually it is reminiscent oF IAPT’s approach to assessment, resulting in a treatment, that by my independent assessment, has a 10% recovery rate -‘the tip of the iceberg respond’.



The mental health services are it seems like the like the Titanic heading towards the iceberg, hopefully unlike the crew they will heed warnings and take a new direction.

 Galea et al (2005) ‘The Epidemiology of PTSD After Disasters’ in Epidemiological Reviews


Dr Mike Scott




Grenfell Fire – A Cunning Plan?

Yesterday a Counsellor from the Children and Adolescents Mental Health Services (CAMHS) announced on the BBC News, that staff are going to go door to door asking whether the occupants want professional help. Is this really the best use of resources 6 months after the tragedy? The days news also contained an item on a parent averting the gaze of her children from the Grenfell Fire Tower Block as she took her children to school.

Without health staff having a clear understanding of what in effect constitutes the ‘bruising/ tissue damage’ from  the Tragedy as opposed to that which constitutes ‘disorder’ scarce resources are likely to be squandered. There is clearly a role for a preventative/ 1st Aid input, information about not blocking intrusions, the normality of a period of increased irritability, anxiety about rehousing but there also has to be a reliable assessment of dysfuntion so that an evidence based treatment can be highlighted.

Dr Mike Scott

I’ve Had 10 Diagnoses, Got This Disorder For Life

A teenager Bex’s despair at our mental health system . Twice she has been refused Hospital admission when suicidal. ( Radio 4 today full transcript on Newsbeat ‘Me and My Mind’ available on i-player.  Jeremy Hunt Health Secretary responded ‘only had Crisis Teams 3 years ..it takes time, help isn’t happening everywhere’, he might have added nor does it look like happening anytime soon.

Bex complains that she has OCD, repeatedly checks windows etc, her thoughts sometimes make her too fearful to leave home ‘all thoughts going over, no off switch, tight, chest. It is extremely unlikely that she actually has 10 disorders, but as comorbidity is the norm doubtless she has a couple of disorders. It is inecusable that these  disorders have not be reliably identified and treatment pathways for each illuminated. Making treatment available doubtless requires increased funding but just as importantly the monitoring of fidelity to evidence based treatment protocols for the identified disorders.

I’d like to think of Bex’s case as exceptional, but she reminds me of a former client of mine who unquestionably had a primary diagnoses of borderline personality disorder (BPD). I discovered yesterday that she dropped out of treatment at the behest of a drug taking boyfriend. Since she has done the rounds of local mental health services who have labelled her as having bipolar disorder and she is taking Lithium and having therapy in secondary care. To her family’s dismay she continues to create chaos, her mum has to look after her baby etc. Once again a failure to address the key problem.


Dr Mike Scott

The Failure To Deliver Quality Child Mental Health Services

Children and adolescents are failed not only by an underfunding of services  ( see The Guardian, Sunday  December 3rd) but by an aping of models based on IAPT for adults.

I have just seen a 10 year old who had 8 counselling sessions, completed a wide range of psychometric tests, mum was allowed to attend the first ‘assessment’ session. At the end of treatment the agency declared that he had made ‘excellent progress’ and the child thought treatment was ‘fine’. But the reality is that the only disorder he was suffering from before counselling was separation anxiety disorder, when I re-examined him with his mum after treatment there had been no significant change in his diagnostic status. He was happy to chat about anything other than being separated from mum. Inspection of the counselling notes  mentioned working on self-esteem, work with play dough and breathing techniques. Mum had felt excluded from treatment and reported his recent ‘melt down’ when she briefly lost him coming out of a cafe.

Unfortunately neither a diagnostic competence nor ensuring fidelity to an evidence based protocol figure anywhere in IAPT and when agencies ape it, it is no surprise that the results are very poor. Appointing a counsellor in every school sounds good in that the child does not have to go to a mental health establishment and teachers could act as reality checks that ‘treatment’ is making a difference.  But the ‘caseload’ and training remain to be determined. In principle working in a school gives the opportunity  for the counsellor to engage in preventative work, but we have no hard evidence that this works. Nobody it seems has yet addressed the question of the right balance between preventative work and treatment. I can foresee a situation in which the counsellor becomes overwhelmed by the volume of work and redefines their role in a Citizen’s Advice Bureau manner acting primarily as a signpost, doubtless labelled Step 2 making no real world difference

Dr Mike Scott

Evidence Base for CBT Depends On How You Focus The Camera

What NICE says about the efficacy of CBT has been taken as gospel, but Moriana et al (2017) have pointed out that what other similar bodies say is significantly different. The actions of practitioners are micro-managed by august bodies such as NICE (via IAPT), Division 12 (Clinical Psychology American Psychological Association, Cochrane and the Australian Psychological Society, an essentially top down process is in operation.  But which, if any should be the determinant?

Rather than arguing about which body has produced the best synthesis of outcome studies the focus should shift to bottom up, asking how does cbt fare in routine practice?

Tolin et al (2015) have suggested that a treatment should only be regarded as effective if there has been a randomised controlled trial of the intervention in routine practice using non-specialist therapists, further the researchers should be independent of those who originally developed the treatment.  This has been adopted by the American Psychological Association. An additional requirement should be that the ‘gold standard’ entry requirement for the trial, admission by a standardised diagnostic interview, should also be the primary outcome measure as assessed by independent blind assessors.  Only in this way can it be known whether the treatment makes a real world difference i.e it will be known that x% no longer suffer from the disorder at the end of treatment compared to y% in the control condition. Without these diagnostic strictures one ends up with the highly questionable conclusion of Pybis et al (2017) that cbt and counselling are equally effective. Tolin et al (2015) have suggested the external validity criteria have been fulfilled in the case of CBT for OCD, but when we look at other disorders such as trauma focussed cbt for PTSD it is doubtful that it clears such a high methodological bar, for example the supposed replication of Ehers et al  CBT for PTSD (2005) by Gillespie et al in Northern Ireland did not involve a standardised diagnostic interview as the primary outcome measure, further there were no independent assessors.

It may be that the struggles of practitioners to achieve performance targets are not so much to do with their deficiencies as inherent in the context within which they are working. Singling out ‘poor performers’ may be unjust in extremis. Pybis et al (2017) concluded that ‘half of all patients (IAPT clients) regardless of type of intervention (counselling or CBT) , did not show reliable improvement’, leaving aside whether the IAPT self-report mesasures they review are at all meaningful, are half the therapists going to be put in the dock?

Ehlers, A et al (2005) Cognitive therapy for PTSD development and evaluation. Behaviour Research and Therapy, 43, 413-431.

Gillespie, K et al (2002) Community based cognitive therapy in the treatment of PTSD following the Omagh bomb. Behaviour Research and Therapy, 40, 345-357.

Moriana, J.A et al (2017) Psychological treatments for mental disorders in adults: A review of the evidence of leading international organizations. Clinical Psychology Review, 54, 29-34

Pybis, J et al (2017) The comparative effectiveness and efficiency of cognitive behaviour therapy and generic counselling in the treatment of depression: evdence from the 2nd UK National Audit of psychological therapies. BMC Psychiatry, 17:215

Tolin, D.F et al (2015) Empirically supported treatment: recommendations for a new model. Clinical Psychology Science and Practice, 22, 317-338.

Dr Mike Scott