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BABCP Response - NICE Consultation January 2022

Piracy in NHS Talking Therapies

The initial press-ganging of patients is conducted by a Psychological Wellbeing Practitioner (PWP). He/she is the least qualified member of staff. Nevertheless, the PWP determines the ‘vessel’ on which the patient is put. At best, the patient can vote with their feet. There is no indication of the ‘soundness’ of the vessel for them.

Here is an extract from a letter to the GP following an initial assessment by a PWP:

‘The difficulties as described at assessment appear consistent with PTSD although this is a description of symptoms and should not be considered a diagnosis’

Nevertheless, the PWP specifies an ICD-10 code for PTSD. Following the 40-minute telephone assessment this patient has 3 sessions of low intensity group treatment. The trauma in this case was a physically threatening altercation at work. But inspection of the DSM-5-TR stressor criteria for PTSD states that only an extreme trauma is the gateway to PTSD and that it is ‘extreme’ in that it is sudden and catastrophic Noorholm et al 2021. The PWP’s idiosyncratic use of diagnostic criteria is precisely what is condemned in DSM-5-TR (2022) P23 ‘lack of familiarity with DSM-5 or excessive, flexible and idiosyncratic application of DSM-5 criteria substantially reduces its utility as a common language for communication’. Noorholm et al 2021 also point out that the DSM-5 stressor criteria should be established using a standardised diagnostic interview and not be based on a self -report measure alone.  The PWP used a PTSD self-report measure on most occasions, and followed NHS Talking Therapies customary practice of routinely using the PHQ-9 and GAD-7.

Notwithstanding the above considerations there is no evidence that 3 sessions of group therapy makes a real-world difference to a person with PTSD. It is not an appropriate vessel for them to be put on. There is no evidence that the PWP or patient was aware of this. The patient is a victim of traffickers/organisational dictate. Informed consent is notable by its’ absence.

The patient is then switched ‘vessel’, with group sessions followed by 5 individual high intensity sessions of CBT. But there is no evidence that this dose of CBT makes a real-world difference to patients with PTSD – journeying once again on an ‘unsound vessel’. Unsurprisingly the high intensity therapists decides to switch the patient again to another ‘vessel’, EMDR. The patient then has 13 sessions of this, involving re-living of the altercation. But EMDR is only a NICE approved treatment for PTSD. The patient has had extensive inappropriate treatment. At the final session the female patient reports that the ‘memories …. don’t bother me much anymore’. But the avowed purpose of EMDR is to achieve such a response, the patient would feel that they were failing the therapist and themselves not to report such an improvement – the demand characteristics of therapy. Similarly changes on the PHQ-9 and GAD-7 could also reflect the demand characteristics and/or simply the passage of time.

A more plausible explanation of the patient’s difficulties was that they suffered a chronic adjustment disorder that would be in place until the employer ensured the safety of the patient. The extensive treatment has involved a psychopathologizing of the patient’s difficulties. It has also been a massive waste of psychological therapy resources. Assuming the high intensity therapy was costed at £100 per session the cost would be £1800. Assuming the group sessions cost £70 each the total cost would be £210 and the individual assessment by the PWP at say £80. The total cost of therapy would be £2000+.

The patient has been taken on an unnecessary and costly journey that could have been avoided with careful assessment, followed by watchful waiting. It is the public purse and patients that are the victims of this piracy.

Dr Mike Scott

2 replies on “Piracy in NHS Talking Therapies”

This is the absolute norm in IAPT and mental health services in general and i’ve sat in with plenty psychiatrists making a ‘diagnosis’. I don’t see how diagnosis can help. Just because more people are likely to agree on a label using a structured interview doesn’t make it so. The criteria for each alleged ‘disorder’ are voted into existence by committees of people often with ties to drug companies. In light of this and so much more that is wrong with diagnosis in mental health how can we attribute any legitimacy to an assessed label when the structure is made from smoke and mirrors? where are these human beings that fit into neat treatable boxes?

I remember reading an interview with Robert Spitzer and his reasoning for setting a particular number of ‘symptoms’ for a diagnosis of MDD and not say (eg) 12 or 5 – his reply was 12 sounded to many and 5 to few. oh so scientific.

I’ve just read an excellent recent book that looks at the history of psychiatry through the lens of ignorance, I found it illuminating. It is this ignorance that still fuels psychiatry and the dangerous twaddle that spews fourth from it – I wonder can we find a way of moving on from it?

This is a good interview with the author https://www.madinamerica.com/2023/02/psychiatrys-cycle-of-ignorance-and-reinvention-an-interview-with-owen-whooley/

In this blog I have been able to challenge the operation of NHS Talking Therapies by an insistence on reliable diagnosis using a standardised diagnostic interview. It was within this framework that the randomised controlled trials of CBT for depression and the anxiety disorders were conducted from the 1960s onwards. Prior to this there were no agreed criteria on anything, making research impossible. In a 1962 paper Aaron Beck addressed this issue by focussing on the need for information and criterion variance. He was not promoting psychiatry, simply facilitating a discussion that would lead to answering the question ‘what works with whom?’. Whoolley’s historical review totally misses this, in an anti-psychiatry polemic. Without realising it, he is turning the clock back 50 years. I remember those days well, it was chaos with social workers, psychologists all doing their own thing. On a course I had the temerity to ask did casework, work? My card was marked. You were expected to conform to the course ideology and woe betide you if you didn’t.The only redress has been evidence-based psychological therapy which rests on a bedrock of reliable diagnosis. Merely calling for the end of diagnosis in mental health adds nothing at all, no improved treatment, no improvement in the lot of litigants. It is perfectly possible to abuse diagnosis in the way nuclear energy can be abused but it doesn’t invalidate the latter. Unfortunately, in practice diagnosis is most often abused, but it doesn’t have to be.
Mike

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