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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