Dire Consequences Of Unchallenged Diagnostic Labels

‘Angela’ lost access to her 3 children, because a psychiatrist said she had an ‘Emotionally Unstable Personality Disorder’. When challenged he claimed 4 other clinicians had said the same! It is a classic example of the dire consequences of ‘sticky labels’, the passing on of a diagnosis without rigorous critical appraisal.

In submission to the Court I challenged the psychiatrist’s diagnosis thus ‘he seems unaware of the operation of ‘Diagnosis momentum: once diagnostic labels are attached to patients they tend to become stickier and stickier. Through intermediaries (patients, paramedics, nurses, physicians), what might have started as a possibility gathers increasing momentum until it becomes definite, and all other possibilities are excluded’ [ Crosskerry, P (2003) The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine, 78, 775-780]. Further the category of Emotionally Unstable Personality Disorder, Borderline Type is never used for research purposes, because to my knowledge there are no studies of its’ reliability [i.e the level of agreement (kappa) amongst a group of clinicians independently viewing the assessment of the same person] instead use is made of the comparable Borderline Personality Disorder in DSM-5 which has very explicit diagnostic criteria and requires assessment of each symptom in a criteria set, in my book Towards a Mental Health System That Works (2017) London Routledge I reviewed evidence that the kappa for DSM defined Borderline Personality Disorder is 0.54 making it a reliable set of symptoms, further when I assessed ‘Angela’ using the DSM criteria for Borderline Personality Disorder she did not meet the criteria’.
In the event the Expert Witness appointed by the Court agreed with me that the psychiatrist had got it wrong, and neither he or his like-minded clinicians had utilised agreed criteria. But all this did not happen until Social Services looked at ‘Angela’s’ behaviour entirely through the lens of Emotionally Unstable Personality Disorder depriving her of a family life.

Dr Mike Scott

Gross Abuse of Power – Misdirection of Therapy A Bigger Scandal Than The Misselling of PPI’s

I mentioned in an earlier post that a former client of mine, ‘Angela’, lost contact with her children because a psychiatrist diagnosed her as having an ’emotionally unstable personality disorder’.

The case has now been partially heard in Court and an Expert Witness agreed with me that the diagnosis was unfounded, as there had been no adherence to the agreed diagnostic criteria for the disorder. In the interim, despite my protestations, Social Services  were insistent she attend Group Mentalisation Therapy, a treatment targetted at people with a personality disorder. Social Services refused to respond to my two reports. To date ‘Angela’ has increased access and the legal case against the local authority is ongoing, I and ‘Angela’ are therefore limited in what we can say at this stage. But cavalier diagnosis and misdirected therapy are a national scandal. ‘Angela’ is happy to write on this Forum at the conclusion of the case. The horrors she has endured are unspeakable and a consequence of a systemic abuse of power in Health and Social Services.

Dr Mike Scott

Discussion With National Audit Office Re: IAPT

On Monday I received a thoughtful, considered and detailed response from the National Audit Office with regards to my submission re: the IAPT investigation. I’ve just penned the following response:

  1. In 2011 the Secretary for State for Health, Andrew Lansley MP and the Minister of State for Care Services, Paul Burstow, MP said stated ‘we are clear that building services around the outcomes which matter to people is the very essence of personalisation’, [Transparency in outcomes a framework for quality in adult social care (2011) Department of Health] so it cannot be for IAPT to choose the yardstick by which it evaluates itself. People seek physical/ psychological treatment in the hope that they will no longer be suffering from an identified disorder by the end of treatment, this is not a matter of clinical judgement, the yardstick is primarily patient driven. If an agency supplies data that does not allow a determination of whether this transparent yardstick is met, then they are remiss. In this connection IAPT ought to be brought to task by the National Audit Office.
  1. Psychometric tests of themselves do not point to any particular NICE approved treatment, if they had this power NICE would have said so, and they did not. Tests are like road signs blowing in the wind, they can only give direction if anchored in a reliable diagnosis. Inappropriate treatment including a failure to treat ( false positives and false negatives) is inevitably ubiquitous when treatment is not moored to diagnosis. Whilst it is the case that some cut offs are better than others at identifying a ‘case’ of disorder, the  cut offs themselves vary from sample to sample depending on the prevalence of the disorder and are at best relevant to one disorder – in practise people usually have more than one disorder. IAPT essentially has two instruments the PHQ-9 and GAD-7 which they purport measure anything of significance, no medical/scientific professional would claim such powers for just two instruments.
  1. I am unsure whether the National Audit Office are aware of the paper by Griffith’s and Steen (2013) [Improving Access to Psychological Therapies (IAPT) Programme: Scrutinising IAPT Cost Estimates To Support Effective Commissioning, The Journal of Psychological Therapies in Primary Care, 2, 142-156]. that suggest that the cost of IAPT therapy sessions is 3 times more than the Department of Health Impact Assessment estimates and this may lead to very different conclusions about the cost-effectiveness of IAPT. For ease of reference I attach a copy of this paper.
  2. How has the IAPT data set demonstrated that it offers added value over a) services as they existed before IAPT b) non-IAPT services in Wales, Scotland and Northern Ireland? In the absence of such a demonstration it can be questioned whether IAPT overs value for money.
  1. It may be that one part of IAPT say high intensity therapy, is value for money but say low intensity (the most common modality) is not but no such analysis has been proferred. Why?

 

Dr Mike Scott

CBT for Addictions – As Likely As Winning At Roulette

There has been an outbreak of smashing fruit machines in Liverpool: this week a man was given a 12 month suspended sentence for wrecking a well known Bookmakers machines, he protested that they were not helping him overcome his addiction! This followed hot on the heels of the brilliant fictional TV series ‘Broken’ (filmed in Liverpool) which showed identical behaviour in the wake of the suicide of a gambling addict.

A person I saw recently Mr X ,with a lifelong gambling addiction told me that the longest period he had been without gambling was when he bet a fellow gambler who would last longest, he lasted 2 weeks. Sadly his experience of IAPT was woeful he was introduced to the discredited stop technique to distract himself when he had the urge to gamble.  He said that he had a few sessions with the therapist but the therapist left and he was given a new therapist.  Mr X said that a questionnaire was then administered and because he got below certain thresholds it was deemed that he did not need counselling and the therapy was terminated.  He said that he was alarmed at this because he felt suicidal and he wrote a letter of complaint and was then offered further sessions but declined them because he had lost trust in the enterprise.

Addiction services have been managed by local authorities since 2012 , but with typical cuts of 30% many services struggle. People can fall between services as a tender is often times switched after 3 years.

CBT for Severe Mental Illness – Does It Reach the Parts That Matter?

Is IAPT overeaching itself by straying into the Severe Mental Illness arena? ‘Ian’ had a life long history of psychosis, he had a great deal of support/treatment over the years from Richard Bentall, author of the brilliant book ‘Madness Explained’, for which the family were most appreciative.  Unfortunately Ian had his benefit withdrawn on the grounds that he was ‘fit for work’ and I was asked to help. Within  two minutes of my seeing  Ian it was abundantly obvious to anyone that he could not work, he was so agitated,  his visits to coffee shops often curtailed by his paranoia.  In the event I produced a report, which alongside a letter from Richard resulted in his benefit being reinstated, his parents were delighted. I did offer Ian the opportunity to look at better ways of handling his paranoia etc but he declined.  I felt desperately sorry for him and reflected that even if he had taken up my offer I doubt that I would have made a real world difference, at best he would have been thankful for my efforts. I wonder whether CBT for psychosis has been oversold.

In using the term ‘severe mental  illness’ I toyed between this term and psychosis, I was trying to use a common language with the reader and in writing my report to the DWP I said that Ian met the DSM diagnostic criteria for schiziophrenia. Labels can be problematic and indeed might not have a biological basis but they give a direction for treatment and influence eligibility for benefits. Richard Bentall et al wrote an Expert review ‘Drop the language of disorder’ in Evidence Based Mental Health, February 2013 and recommended a ‘problem definition, formulation’ approach rather than a ‘diagnosis treatment’ approach, but in my view it is not a matter of ‘either or’ but a matter of both.  Notwithstanding our differences neither of us were able to make a real world difference in what I would see for want of a better term is Ian’s schizophrenia.

IAPT has a demonstration site for Severe Mental Illness for people with psychosis, bipolar disorder and personality disorder, before disseminating such a service there needs to be independent verification using clinician-rated measures (PSYRATS for hallucinations and delusions, SCID for personality disorders) that such a such service would add anything over and above support in the community, otherwise it is just extending an empire.

Dr Mike Scott

‘Too Complex for IAPT’ – Dumping on Secondary Care?

I work in secondary care as a band 7 CBT therapist within a CMHT. Often I will have referrals sent directly from IAPT who describe the patient as being too ‘complex’. Indeed this seems to have become an actual care pathway (not that we have too many of those). As far as i can tell at this stage  the patient may have not had a face to face assessment, rather has been deemed too complex simply because of the stated diagnosis e.g if they have a so  called personality disorder. I have also been told that if someone scores a above a certain score on the HADS scale (I don’t understand why this particular measure is being used as the ‘cut off’)  they too are apparently ‘too complex’. I am also told that  the outcome measures used by IAPT apparently mean that the ‘too complex clients’ would impact on these performance scales which in turn  could mean further funding for the service is jeopardized.

This concerns me on two fronts. Firstly in principle… this seems to completely  go against the ethos  of  the IAPT envisioned by Layard & Clark (although how workable or realistic this ever actually was in another thread) and another example of how it  seems management  are ‘cooking the books’ . Secondly on a more  personal level  I am employed in same Trust as a band 7 cbt therapist , i have no support from care coordinators and supposedly have the same amount of sessions to offer patients so how can possibly i offer anything different to IAPT? I suspect management know I can’t , but i ( and my colleague) serve as  i convenient sponge to soak up all the pts that may threaten the outcome measures…

 

I wonder has anyone else working in secondary care had  similar experiences  or is this an isolated thing ?

Wasting The Taxpayers Money – Fire and Fury Over CBT

‘The results are, at best, unreliable, and at worst manipulated to produce a positive-looking outcome’ so write the editors of the current issue of the Journal of Health Psychology, (http://journals.sagepub.com/toc/hpqa/current). They are writing in relation to a study of the efficacy of CBT for chronic fatigue syndrome ( CFS – the PACE trial). The essence of the editors’ criticism is that when objective measures of outcome were used the effectiveness of CBT disappeared, but the authors of the PACE trial relied instead on subjective self-report measures to ‘promote’ the cognitive behaviour therapy and graded exercise therapy protocols that they themselves had developed. The Times of August 1st 2017 reported a ‘trade’ of ‘insults’ between both sides.

                       PACE Trial £5 million

                                                                                           IAPT £400 million +

But the same criticism that the editors make of the evaluation of CBT for CFS can be applied to how CBT for ‘depression and anxiety’ (the alleged focus of IAPT) is evaluated in routine care in the UK Government’s IAPT Service. Evaluation is entirely based on subjective measures (the PHQ-9 and GAD-7), there is no objective measure (a standardised reliable diagnostic interview), assessment has been entirely by the service providers with no independent assessment. The cost of the PACE trial was just £5 million, a drop in the ocean compared to the cost of IAPT which saw the Coalition Government invest up to     £400 million over the four years to 2014–2015. [Department of Health (2012). IAPT Three-year Report—The First Million Patients. London: DH] .

Dr Mike Scott

 

Disseminating Group CBT – What You Need To Know

Clients often have similar stories, so it is a no-brainer to treat those with the same story in a group. But groups can go badly wrong – a colleague of mine was unavailable to lead a group because of illness, one of the group ‘stepped-in’ and ran the group at his flat, suggesting that he would be a much better group leader!

On September 6th I am giving a 1 Day Workshop on Delivering Group CBT to Bedford IAPT, one of many I have delivered to BABCP local Groups and IAPT. In 2013 when I gave the workshop in Copenhagen I discovered that  there Group CBT is the usual mode of service provision and therapists have to justify individual therapy, they found it surprising that in the UK we  did not operate that way. There are free group materials for depression, anxiety disorders and PTSD if you click the Resources button on this site, from Simply Effective Group Cognitive Behaviour Therapy (2011) London: Routledge. The Workshops have raised a whole host of questions that might be worth discussions in your locality and/or on this forum:

 

 

The learning objectives for the Delivering Group CBT workshop are for attendees to be able to answer most of the following questions by the end of the day:

  1. How do we ensure that we don’t play a numbers game with regards to groups?
  2. Why not admit all-comers?
  3. Aren’t classes a better use of resources than groups?
  4. How do we select the right people?
  5. Is group CBT really an answer to a Manager’s prayer?
  6. How do you identify and circumvent special problems in marketing group CBT?
  7. How can you integrate individual and group cbt?
  8. What is the structure of a session?
  9. What might the session by session content look like for depression and the anxiety disorders?
  10. How do you capitalise on group members assembling and/or departing?
  11. Do you have to specify groundrules?
  12. How do I handle clients with more than one disorder/difficulty in a group?
  13. How do you handle the difficult client?
  14. How do I know if the group is making a socially significant, real world difference?
  15. Which groups are best to start with?
  16. How do I manage group processes?
  17. How can I know whether I am managing group processes well?
  18. How does group cbt compare to individual cbt in terms of effectiveness?
  19. What if you are expected to run a group alone?
  20. How do you divide up the work between leader and co-leader?
  21. How should leader and co-leader debrief each other?
  22. Can you really do Socratic dialogue in a group?
  23. Are there advantages to a story telling/narrative approach in groups?
  24. What are useful materials?
  25. What can you do if your supervisor has no experience of group CBT?                                                    Dr Mike Scott

Mental Health Services Expansion Before Completion of Investigation!

On July 31st 2017, the Health Secretary, Jeremy Hunt announced funding for an extra 2,900  new therapists in Adult Mental Health talking therapy services. A week earlier the National Audit Office invited submissions for its’ investigation into IAPT, with a closing date of this Autumn. It is clearly the time of the year for the Mad Hatter’s Tea Party:

 

be careful that you don’t mutter under your breath at such gatherings that ‘evidence should precede action’, if heard it could be ‘off with your head’.

But beware, the historian High Trevor Roper wrote in the Last Days of Hitler ‘mythopoeia is a far more common characteristic of the human race than veracity’. The wholesale endorsement of IAPT by BABCP and to a lesser extent by BPS reflects mythopoeia:

 

IAPT with its low intensity modality has attempted to make therapy ‘simpler’ than simple, resulting in ineffective treatment.  When it comes to the high intensity modality it has made matters ‘simpler’ than simple, by abandoning reliable diagnosis/high specification of problem/s as a Sat Nav for treatment again often resulting in ineffective treatment.

 

Dr Mike Scott

 

National Audit Office IAPT Investigation, Whistleblowers

Below is the National Audit Office’s request for evidence re: IAPT, I note they have a whistleblower’s policy. It may be possible to ask for anonymity. I would hope that BABCP and BPS would make a submission to the National Audit Office, but to my knowledge this is not on the agenda of either, why not?

Investigation: Improving Access to

Psychological Therapies performance data

The ‘Improving Access to Psychological Therapies’ (IAPT) programme increases access to

National Institute for Health and Care Excellence approved treatment for depression and

anxiety disorders. In October 2014, the Department of Health and NHS England

jointly published Achieving Better Access to Mental Health Services by 2020. This set new

standards for the time people should wait for mental health treatment and the care they should

be able to access. In the case of IAPT services, the standards are that 75% of people referred

should be treated within six weeks, and 95% within 18 weeks of referral, and that 50% of

those who complete treatment will recover. NHS Digital publishes monthly statistics

that report performance against these standards. This investigation will establish the facts

around how the national statistics are prepared.

If you would like to provide evidence for our study please email the study team on

enquiries@nao.gsi.gov.uk, putting the study title in the subject line. The team will consider the

evidence you provide; however, please note that due to the volume of information we receive we

may not respond to you directly. If you need to raise a concern please use our contact form.