Thursday 24 April 2014

On March 28th 2014, I was made redundant from the UK NHS mental health services after 37 years of full time work. The process, necessary because of extreme financial pressures and the need for large cost savings, was done correctly and through a formal process of consultation over a period of a year or so. It leaves me free to pursue my true work - my continuing explorations in the field of 'energy psychology', and my own particular contribution that I call Psychoanalytic Energy Psychotherapy [PEP].

This blog contains my evolving reflections on my near four decades of experience in the National Health Service - its value, its problems, and its political context. The views expressed are my honestly held opinions and perspectives, but these are subjective. On a matter as complex and richly variegated as the NHS, an objective position is elusive - and others may disagree with some or all of my observations and conclusions. 

My original professional background is clinical psychology - and I obtained a masters and professional qualification in clinical psychology from Leeds University in 1976. I trained in psychotherapy whilst working at the Tavistock Clinic, graduating in 1985 - and undertook a PhD through a link between the Tavistock and Brunel University (studying shame and disturbances in the experience of self). Somewhat later I undertook a (very long and very helpful) training at the Institute of Psychoanalysis in London. However, my work in psychiatric settings left me dissatisfied with the value of conventional talking therapies for those who have suffered extensive trauma (as many psychiatric patients have) - and this led me to an ongoing exploration and enquiry into supplementary modalities that might more effectively ease the suffering of the severely traumatised. In the 1990s I trained in EMDR and found this helpful. Through EMDR colleagues I learnt of the emerging field of 'energy psychology' and have found this family of approaches to be the most effective and gentle means of addressing any kind of trauma, as well as clearing dysfunctional patterns from the mind-body-energy system. I have been studying energy psychology for the last 14 years (i.e. since around 2000) - and am actively involved with the excellent Association for Comprehensive Energy Psychology ACEP

I have known many wonderful and dedicated people working in the NHS, in all professions, as well as clerical, administrative, and reception staff. In mental health services, the admin/secretarial and reception staff are particularly crucial since they are often the first point of contact when a 'service user' is in distress. Such staff, untrained in clinical skills, often do acquire considerable talents in managing human anguish and anxiety, as well as in coping with aggression and hostility. I am grateful to clients and colleagues for 37 very rich and rewarding years of clinical experience. 

I retain much affection for the NHS Trust that I have left. Despite the challenges it faces, I believe (on the basis of reports from both colleagues and patients) that much of the time it manages to provide better care than many comparable mental health services.

This initial post of the blog covers the following topics:

  • the NHS marketplace and its funding
  • the misleading marketing of psychological therapies - critique of IAPT
  • the spurious nature of much psychiatric diagnosis and its consequences
  • problems of diagnosis of physical health problems with psychological aspects - three examples: Ehlers-Danlos Syndrome (EDS); Chronic Regional Pain Syndrome (CRPS); Lyme Disease

The NHS marketplace and its funding
A crucial point to understand about the current NHS is that it is made up of semi-autonomous business units operating in a very strange market-place. Basically, the government provides the money for the NHS, from taxation - giving this money to the local GP commissioning teams. These teams then purchase health care services from a range of competing businesses. 

In a normal market-place, the 'customer' or purchaser would be the consumer of the service or product. This is not the case with the NHS. The customer is not the patient - as would be the case in purely private medicine or psychotherapy. The customer with the money is the local commissioning group. This means that services could be purchased that are not necessarily in line with the desires or needs of the local population but instead reflect the assumptions or prejudices of the members of the commissioning group. The commissioning group can, in turn, be misled by the mis-selling of psychological therapies described below. As a result, a service may be provided that meets neither the needs nor the preferences of the actual consumer. 

NHS Trusts make much of being 'businesses' - and I have even heard them referred to as such in communications with those who use the service (patients). Managers attend trainings in business-oriented skills, and some may acquire an MBA. The problem is that, by and large, those who manage NHS services do not have a background in business, and NHS Trusts are not actually businesses in the normal sense of an autonomous entity selling services and products in a free (albeit regulated) market. 

NHS Trusts do compete with each other, and do behave in predatory ways, bidding/tendering for health care services, sometimes in relatively distant geographical areas. They also devote much energy to the tasks on which payment for their services depends (particularly data quality). Like other businesses, NHS Trusts seek to become lean and efficient, restructuring and cutting to reduce costs. They attempt to provide clinical services as economically as possible by employing staff who can most cheaply undertake the work, whilst reducing the more senior and more experienced and highly qualified staff. Like other businesses, they are concerned with their brand image - the impression given to commissioners and the wider local public. And finally .. as in other businesses, some people in the NHS seem to earn a large amount of money!

There the similarity with normal businesses ends. Within the Trusts is an NHS culture, containing professional rivalries, entrenched power groups (particularly the medical staff), wasteful practice, and often inflexible approaches to care. Most managerial staff within the NHS have progressed from an original professional background in nursing or social work - at least this is the case within mental health services, where I have most experience. They have not worked in the business world - even if some have acquired an MBA. There is an extent to which NHS Trusts, and their top managers, are mimicking the trappings of business without having developed an authentic and organic role in the increasingly 'privatised' healthcare service. 

The NHS is being steadily 'privatised' whilst maintaining a service that is 'free at the point of delivery' and paid for by general taxation. This has been done in a step by step ''stealth' manner - as outlined in the excellent and factually detailed book The Plot Against the NHS by Colin Leys and Stewart Player (Merlin Press. Pontypool. 2011). Private health-care organisations and individual members of governments have benefited considerably. According to this book, it seems not uncommon for a government minister to foster links with private healthcare organisations and subsequently to leave politics and work as a consultant for those organisations. 

The NHS has suffered extensive cuts in recent years. The first of these severe rounds of cuts took place during the last Labour government, under Gordon Brown's leadership. For reasons that have continued to puzzle me, that government managed to pour a huge increase in funds into the NHS, only to result in a crisis that brought about very severe cuts in services, and redundancies, within the Trust that employed me. Our own Trust had balanced its financial books well, but the surrounding NHS services had run into a huge deficit, to which our Trust was required to make a substantial contribution. This was long before the global financial crisis of 2008 onward. It followed the awarding of large increases in medical salaries, and changes to GP contracts. Some speculated that the government had simply got its sums wrong. 

In relation to the more recent cuts in services, it has been explained to us that in order to maintain existing services, the NHS requires an increase in funding of about 5% per annum, due to increased costs and demographic pressures. If funding is 'protected' but not increased at this rate, the effect is actually a cut. Over a five year period, this would amount to a cut of 25%.

The Institute for Fiscal Studies publication NHS and Social Care Funding: the Outlook to 2021/22 states:

"A four-year real freeze in English NHS spending between 2011/12 and 2014/15 .. would be likely to be the tightest four-year period in the last 50 years"
Such circumstances appear to have been a major contributor to my being made redundant, along with a number of other senior colleagues. 

The NHS appears to be an easy market to exploit. Dubious marketing activities of the pharmaceutical companies are well-known. It is entirely commonplace for drug companies to fund generous lunches and conferences for medical doctors - all with the aim of encouraging a favourable attitude toward their products. I also have the impression that the companies that provide stationary and other standard items may tend to charge higher rates than could be found by shopping around. In the case of less routine, or more occasional purchases, instead of looking online for the best value, in the way that a private individual would, the procedure often appears to involve ordering through an NHS supplier that gives far from good value. 

The marketing of psychological therapies
An area of exploitation with which I am more familiar is the marketing of psychological therapies. There is much 'over-selling' of psychological therapies.If we look at the research evidence for psychological therapies bringing about a complete and lasting resolution of a problem, it is hard to escape the conclusion that, much of the time, they are not very effective. 
 In general, psychological therapies can certainly be of some help, but are far from the panacea that is often implied. CBT seems to be recommended for almost every psychological (and even physical) problem these days - although the joke among practitioners is that anything that works gets called CBT, as that 'brand' promiscuously incorporates everything from Pavlov's dogs to Buddhist meditation. Although there are different traditions of psychotherapy, there is also much overlap. Each tradition contributes some important elements, but experienced practitioners tend to become more flexible and integrative over time. There are some therapists who are method-centred, placing allegiance to their preferred model and method as the primary determinant of their clinical work - but most (particularly in the NHS) who are client-centred will modify their style and method to suit the needs of the person they are trying to help. In general, those therapeutic approaches that are more helpful tend to contain the following ingredients: 

  • a supportive therapeutic alliance is developed;
  • therapist and client work co-cooperatively to find a resolution of the problem; 
  • there is a gradual exploration of the clients thoughts and feelings, and an examination of the interpersonal context in which they arise; 
  • the client's developmental history is explored, looking at important formative experiences that have contributed to the person's core beliefs and expectations;
  • the client is helped to look at situations and problems from different points of view; 
  • empathy and compassion are provided, and these help foster the client's own empathy and compassion towards the self;
  • there is exploration of the client's maladaptive attempts at solutions to problems, often involving attempts to avoid emotional pain (through addictions and impulsive behaviours etc)
  • the client is encouraged to face situations that are avoided (both external situations and inner emotions), and to try to find realistic adaptive solutions to alleviate life's problems.
These components are found in most (perhaps all) of the main forms of psychotherapy - although the brand names of the therapies may be different and certain aspects of the style and format of the sessions may be different. Some approaches are relatively superficial, whilst others explore areas that are initially more deeply unconscious - but all will involve some degree of talking and exploration. Some will include additional elements intended to calm the body, mind and brain, and some will have a focus on bodily sensations as a component of emotional awareness. It seems to me an obvious conclusion that a clinician wishing primarily to help his or her clients will draw upon effective components from different traditions in order to facilitate the individual's idiosyncratic journey of emotional healing - a therapeutic approach that is commonly called 'Integrative'. However, Integrative approaches do not feature in NICE guidelines, current 'care pathways', or in any NHS lists of recommended psychological treatments. In fact, they are discouraged - the emphasis being upon ensuring that practitioners stick to the agreed manuals and protocols for each 'brand' of therapy. There is no clinical justification for this emphasis on purity of approach, which essentially serves the needs of those who market the therapies. The more experienced and effective clinicians within the NHS manage to develop some creativity and flexibility despite this increasingly rigid focus on manualised 'brands'. 

When I first began training in psychology and psychotherapy, the idea of marketing psychological therapies (in the UK) would have seemed incomprehensible - not least because psychotherapy was seen as a very low priority for the NHS. Now, the selling of psychotherapy brands, with associated training, supervision, accreditation etc. has become a substantial industry. In my view, this is essentially a dishonest process. The reason for this harsh assertion is simple: the most consistent finding in many decades of psychotherapy research is that when genuine psychological therapies are compared, there is little or no difference in outcome. By 'genuine psychological therapies' I mean ones that psychotherapists actually use, rather than spurious control group conditions that are quite unlikely to be of help. There is more variation between therapists than between therapies. What this means basically is that some therapists are effective and some are not so effective, regardless of the approach they use. There is useful research into the qualities of effective therapists (or 'supershrinks' as they are called in this context!) I have explained this at greater length in these articles:
Truth about Psychotherapy Our rich heritage - are we building upon it or destroying it?

The problem began with an admirable effort in the 1990s to begin to establish what forms of psychological therapy were most helpful for what kinds of problems, resulting in the book What Works for Whom? by Roth and Fonagy [Wiley 1997 - 1st edition]. Whilst this was a useful summary of certain kinds of research, it relied heavily on randomised control trials, generally considered the 'gold standard' form of evidence. It was not concerned with factors in the therapist, or in the therapeutic process, that contributed to the outcome for the client - and thus essentially discarded a huge amount of the most interesting psychotherapy research. A more useful book, in my view, is Mick Cooper's Essential Research Findings in Counselling and Psychotherapy [Sage 2008], which shows much more concern for the subtleties of the psychotherapeutic process and relationship. Unfortunately, the Roth and Fonagy book set the scene for the comparison, and then marketing, of psychotherapies as if they were analogous to pharmaceutical products - a trend that became even more deeply rooted with the increasing dominance of the NICE guidelines. I have outlined some of the problems with the NICE guidelines in relation to psychotherapy in the following article: NICE Guidelines are Misleading

When psychological therapies are treated as quasi pharmaceuticals to be prescribed in standardised ingredients (therapy by manual), according to standardised protocols (i.e. by standardised therapists), the door is wide open for exploitation of the marketplace by skillful entrepreneurs who package a brand, a training, an accreditation process, and ongoing supervision. Individuals and institutions make a substantial income through these means.  Part of how this is achieved is through a spurious emphasis upon purity of method - along the lines of "in this model we do this ... " and guiding practitioners not to veer 'off model' when engaged in the particular brand of therapy. Those undertaking training may be assessed in terms of the rigour of their allegiance to the prescribed model and manual. This emphasis is actually an entirely unjustified application of a requirement for model and manual allegiance in a research context, where the requirement of the research methodology is that the practitioner adhere closely to a manual in order that one clearly described approach can be compared with another clearly described approach. There is no real clinical requirement for this at all. Those who market these brand name approaches may argue that it is only the clearly described and prescribed model and manual that have been found in the research trials to be effective. However, the quite unwarranted implication of this is that deviations from the prescribed model and method will be less effective - when there is usually no evidence for this whatsoever. For example, Brand X therapy might be based around a manual that instructs the therapist to focus on the patient's current state of mind (mood, emotions, and thoughts) in the consulting room, and to avoid historical transference links to childhood. A research trial may have found Brand X to be helpful for certain kinds of patients. However, this does not in any way tell us that Brand Y therapy, which focuses on helping the patient make links between current states of mind and childhood experiences, might not also be equally helpful. As we have noted, the consistent trend is that whenever genuine therapies (ones that clinicians actually use) are compared, there is little or no difference in effectiveness. Experienced and effective psychotherapists do not rely on manuals or standardised procedures - but will adapt their approach to suit the needs and response of the individual client. It seems to me that the real motive for the emphasis upon purity of model and method may be an economic one (as opposed to clinical or scientific)  - without a pure 'brand' it is not so easy to market the product. The NHS does spend substantial amounts of money purchasing these brand name trainings, with accompanying supervision and other related services.

It is not difficult to create a psychotherapy brand, provided one is sufficiently skilled, intellectually able, and motivated to do so. The task is to take certain elements from traditional psychotherapeutic skills and broad approaches, omitting other elements, creating a slightly new blend (or at least one that can be framed as new, with the help of a few new terms and concepts), and then to make a manual out of it. The resulting manualised approach is then tested to see whether patients benefit. Provided the therapy is at least clinically plausible, and contains elements that are widely recognised to be helpful, the method is very likely to be found to 'work'. Genuine therapies are almost always found to be effective to some degree. People do experience benefit when a therapist takes an interest in them, listens, and presents a different way of looking at their problems - particularly if the therapist appears to have confidence it the approach. This does not, however, mean that the new brand of therapy is actually better than the approach used by other clinicians. However, as the NHS buys into the marketing of 'evidence-based' therapies, those clinicians who choose not to train in the new brands are then seen as providing an inferior service. Those who develop and promote the new brands of therapy tend to argue that it is only by doing so, and thereby demonstrating their evidence-based nature, that any form of psychotherapy can survive in the current NHS. 

When the 'Improving Access to Psychological Therapies' [IAPT] initiative was introduced (by the influential economist Lord Richard Layard), with its bias towards CBT, seen as the main 'evidence-based' approach, many counsellors in GP settings lost their jobs. However the CBT practitioners were not found to be more clinically effective, nor more cost-effective, than the counsellors providing person-centred, psychodynamic, or integrative methods:
Evaluation of IAPT
Cost effectiveness of IAPT
Rosemary Risq: IAPT, Anxiety and Envy
Much is made of the alleged effectiveness of CBT and the IAPT programme - with the triumphant initial claim that 50% of clients suffering from depression and other common mental health problems improve as a result of the approach provided within IAPT. Is this actually very impressive? Perhaps it depends on which side of the 'glass half full or empty' perspective one's bias falls - but I personally worry about the 50% who do not benefit. If a pain killer were advertised with the claim that 50% of people who take the product for mild to moderate pain will experience some relief, it might not appear particularly compelling - but this is what the clinical success of IAPT amounts to. In fact the official figures from October 2008 to December 2012 indicated that only 44.4% of patients recovered with the IAPT programme [ IAPT presentation 2013.] If we look under the surface of later statistics the results are shocking. In the year 2012-13, 43% of  those who completed treatment made a recovery - but in fact only 14% of people referred did in fact complete treatment - so the reality is that only 6% of people referred made a reliable recovery. As Paul Atkinson comments: "The truth revealed by the 2013-13 IAPT Annual report is that the IAPT programme is failing - a truth obscured by its smoke and mirrors of its statistical evidence" - see:  The sorry state of NHS provision of psychological therapy 

Despite the limitations of IAPT, with its rigidly prescribed protocols and manualised therapies, and its modest clinical results, it is now being taken as the model for the rest of the mental health services in secondary care. This is taking place despite the reality that the unimpressive clinical results with IAPT have been with those clients with relatively mild and simple problems seen in primary care; the results with the more complex problems presented by patients in secondary are almost certain to be even less encouraging. The whole IAPT programme, with its huge investment of money, reputation, and policy credibility, appears like a convoy of juggernauts, unstoppable and crashing through barriers of evidence and common sense - now an entity viewed as too big to be allowed to fail. 

In my view, the NHS and its clients (and indeed its staff) would be much better served by firmly rejecting the current spurious focus on brand name therapies, and instead helping practitioners to become as skilled as they can, using a broad range of approaches and perspectives, in order to find what is most helpful for the particular client. This depends to a large extent on enabling the practitioner to be sensitive to feedback from the client. See the research work of Scott Miller and colleagues:
Scott Miller articles
Scott Miller Video: What works in psychotherapy
Duncan and Miller on how to get good results in psychotherapy
International Center for Clinical Excellence
On perusing this material, the unprejudiced enquirer may begin to feel a little angry at the misleading messages propagated by NICE and its proponents within the NHS. 

In my experience, what most clients within the NHS (mental health services) value most is the opportunity to be listened to carefully, by a thoughtful and curious clinician who does not judge and does not leap to unwarranted conclusions, but does respond to feedback and does 'learn from the patient'. These rather basic requirements often seem somewhat rare! Psychiatrists will often be so busy asking their standard questions that they do not allow the client much opportunity for free speech. Psychologists schooled in CBT and other brand name approaches will often similarly be busy structuring the sessions, setting agendas and so forth, so that again the client is not free to communicate in their own idiosyncratic manner. 

Why have the psychologists and psychotherapists within the NHS accepted, colluded, or even actively exploited the flawed assumptions and reasoning behind the NICE-IAPT programme? I have pondered this question deeply over a number of years - and it still puzzles me. To some extent, the programme just seems to appeal to some influential psychologists - it is congruent with how they view the world. These trends are obviously favourable to those who develop, promote, and sell CBT. Others, promoting different therapies, seem to have copied the marketing strategies of CBT - with some success but thereby replicating the fundamental flaws in the reasoning. Perhaps the majority of clinicians within the NHS feel simply too burdened and oppressed - by the pressures of clinical work, the ever-increasing administrative data-inputting tasks, and a professional and organisational culture that can turn a little nasty when challenged - so that they have neither the mental space nor energy to question and challenge the powerful political and market forces with any real vigour. I noticed some years ago that it seemed very difficult to question the validity of NICE guidelines. What I mean is that psychologists tended not to do so - and when I attempted to (in meetings, conferences etc) my experience of the response was as if I had said something so embarrassingly foolish it hardly merited comment. However, as I began to articulate and write my critique of NICE more explicitly, I found that many people seemed to agree. I also encountered active efforts to shut me up (details of which, for reasons of tact and discretion,  I will leave undisclosed).

There is a very positive alternative to the bleak and bland technocracy of IAPT (and its increasing invasion of secondary care mental health services). This alternative is the so-called 'recovery movement' - an approach that has developed from the grass roots, from sufferers getting together to support each other in their particular journey toward health. It is fundamentally 'person-centred':
History of the recovery movement
Wikipedia outline of recovery movement
Rather than prescribing rigid and prepackaged 'care pathways', based on spurious diagnostic categories, it respects the unique nature of the individual and seeks to help that person find their own solutions, methods of coping, and to discover or create a viable place in the social world. Its discourse is kind and compassionate - starkly contrasting with the industrial-economic language of IAPT. Some Trusts, including the one I worked for, have embraced the recovery movement, with very positive results. However, it exists uneasily alongside the other, more malign trends I have described. Moreover, there is the potential for the concept to be misused to justify cuts in services - with a crude argument that people should be encouraged to 'recover' and not become dependent on mental health services!

The spurious nature of psychiatric diagnosis - and its potential terrible consequences
Psychiatric diagnosis has been criticised by psychologists and psychiatrists for many years. One prominent critic was, for example, quoted as saying psychiatric diagnoses are less reliable than star signs! See: Richard Bentall interview & What is Richard Bentall is right? & Special issue of The Psychologist on diagnosis & Interview with Gary Greenberg
The use of the term 'diagnosis' gives a spurious medical respectability to the descriptive process, implying an equivalence to physical disease entities. In fact, most states of mental distress are not discrete conditions (there is much overlap and so-called co-morbidity), and do not have any clearly identifiable underlying physical pathology. When there is reference to the 'symptoms' of a particular 'disorder', this implies an underlying disease entity of which the symptoms are its outward manifestation. In the vast majority of instances - with the exception of those conditions that are to do with clear brain pathology, such as dementia and brain injury - there is nothing beyond the symptoms. The 'diagnosis' is simply a short-hand description of a constellation of characteristics. However, because of its medical trappings, it is easy for people to assume there is a disease, with a specified medical treatment, and a clear prognosis. The most common example of this is the doctor who tells the patient that he or she is suffering from 'depression', that this is due to 'a chemical imbalance in the brain', and that the correct treatment is an antidepressant. 

Here is a little history - both amusing and very serious in its implications. In 1980, the DSM-III (the American psychiatric diagnostic manual) was produced – a vast increase in size from the earlier DSM-II. The task force was led by Robert Spitzer. He had been particularly concerned about the reliability of psychiatric diagnosis since the famous 1973 study by the sociologist Rosenhan called On being Sane in Insane Places. Rosenhan had arranged for 8 non-psychotic confederates to get themselves admitted to a psychiatric hospital by claiming to experience a voice saying a single word (either ‘thud’, ‘hollow’, or ‘empty’). This was the only symptom presented. All were admitted to a hospital. After admission they stopped feigning their experiences. All but one was given a diagnosis of schizophrenia – the other was diagnosed as manic-depressive. When they became asymptomatic, they were considered to be in remission rather than as no longer ill  Once admitted, they were not able to obtain release until they agreed with the diagnosis of the psychiatrists and took antipsychotic medication. Since the reaction of the psychiatric establishment to the publication of this study was disbelief, Rosenhan followed this up by informing the staff of a teaching hospital, where it had been claimed that such misdiagnosis could not happen, that over the next three months one or more pseudo-patients would attempt to be admitted. No such attempt was made – but out of 193 patients, 41 were considered by staff to be pseudo-patients and a further 42 were suspected of being. Therefore Rosenhan concluded that psychiatric diagnosis is subjective rather than reflecting inherent disease characteristics! Spitzer, heading the DSM-III task group had been one of the main critics of the Rosenhan study. He sought to establish clear rules for diagnosis – thus focusing on reliability but ignoring the point that validity of psychiatric diagnosis was in question.

Psychiatric conditions seem to vary in their form and manifestation over periods of time and cultural conditions. Moreover, diagnoses come and go according to fashion. For example, I have noticed that in recent years psychiatrists have become very reluctant to diagnose a person as schizophrenic - preferring instead a diagnosis of 'personality disorder', even when the person is presenting with rather extreme psychotic phenomena. 

It may be more appropriate and truthful to think of psychiatric conditions as, for the most part, just culturally shaped expressions of extreme human distress. In most cases (in my experience), there is stress or trauma as a background to 'mental illness' - experiences that the person has been unable to digest emotionally, even if these are not initially apparent (not necessarily experiences in childhood,but often a combination of experiences in childhood and adulthood). Some people express their distress and anger more outwardly, whilst others direct it more inwardly. Different people favour different mental 'defenses', according to their temperament. Of course, the situation regarding diagnosis is neither simple nor clear cut. Sometimes people are in very disturbed states of mind and are clearly 'ill' and needing hospitalisation, with care from doctors and nurses. 

Perhaps the spurious and misleading nature of psychiatric diagnosis does not matter too much most of the time. It is simply a convenient short-hand, a rough classification of different kinds of distress and human dysfunction, facilitating communication between clinicians. Moreover, some clients/patients seem to like to be given a diagnosis, experiencing some comfort in its seeming clarity and the security provided by a name for their state of otherwise 'nameless dread'. However, there are some situations where inappropriate diagnosis can have terrible consequences. I am thinking particularly of family courts. 

Here is a situation I have encountered numerous times. At some point a woman has experienced mental distress - and has perhaps, at that time, been given a diagnosis of personality disorder, perhaps 'emotionally unstable personality disorder'. At some point, perhaps then or perhaps later, there is some concern about her children's welfare, and social services become involved. The existence of the diagnosis is then used in court as a basis to justify removing her children, perhaps for adoption. A court 'expert' is asked to give evidence concerning the prognosis for this psychiatric condition - often resulting in a damning conclusion that the woman is unlikely to recover sufficiently to be able to provide adequate care for her children. Whilst the reasoning might appear superficially plausible and sensible, what happens is sometimes a travesty. I have observed the following: 
  • the existence of the diagnosis functions to obscure an unbiased consideration of the woman's current functioning - i.e. it is used, in effect, to deny that the woman could possibly be functioning well
  • sometimes a diagnosis of personality disorder is given essentially on the basis that the woman was disturbed as an adolescent, or experienced trauma as a child - regardless of her current functioning
  • the diagnosis is used as a basis for asserting that the woman cannot recover without years of therapy (even if she is not displaying current symptoms of disturbance!)
  • the natural extreme distress that a woman will feel when there is a threat to remove her children is used as evidence of how disturbed she is, thus appearing to validate the spurious diagnosis
These legal processes are horrible and shocking to witness. It is just like a legal variant on the Rosenhan study described above - once a diagnosis is given, it can be very difficult to challenge. Some 'experts' seem to make quite a living out of this kind of work. I happened to come across two expert witness reports by the same consultant psychiatrist, in two separate cases, and noticed that a considerable amount of cutting and pasting went into his reports, as he used the same paragraphs and arguments to support his particular bias and idiosyncratic perspectives. Whilst I did provide an alternative professional view in these cases, my evidence was not considered admissible because I was not the 'court appointed expert'. Some psychologists, as well as psychiatrists, engage in similar provisions of 'expert evidence'.  It is not that I think such experts are always unscrupulous and irresponsible (although some may be) - I am sure that most take their task and responsibility very seriously indeed - rather, I think they are themselves sometimes misled by the unsound assumptions underpinning psychiatric diagnosis, specifically the implication that there is an underlying and enduring pathology that will be present even when the person is in 'remission'. 

And some problems of diagnosis in relation to physical problems with psychological concomitants - three examples:

The current medical system, with doctors tending to be focused on their particular specialty, is sometimes not able adequately to address health problems and conditions that span various physical and mental systems and functions. Like the analogy of the blind men examining an elephant, each will be aware of quite different details, but without being able to see the whole. When none of the different manifestations of a condition seem in themselves to offer an indication of the cause, the tendency is to speculate there is no cause other than the patient's mind or personality. 

One example is that of Ehlers-Danlos Syndrome (EDS), which is associated with hypermobility of joints and other structures of the body - with a spectrum from mild to severe. It can be very disabling. This condition can affect joints (resulting in referral to a rheumatologist), the bowel (resulting in referral to a gastro-enterologist), the heart (resulting in referral to a cardiologist), the brain (resulting in a referral to a neurologist), mental state and cognitive function (resulting in a referral to a psychiatrist) - and there can be yet more systems and specialists potentially involved (including referrals to a pain clinic). None of the specialists, nor the GP, may grasp the underlying condition the patient is suffering from, because none may have particular knowledge of EDS.

When medical doctors are unable to understand or treat a condition, there is a tendency to assume or conclude that psychiatric or psychological factors are playing a significant part - and that therefore the patient's problems are (at least partly) 'in the mind' or are a result of some form of 'personality disorder'. Unfortunately, psychiatrists often seem willing to collude with this assumption and similarly make reference to 'personality disorder', 'emotional overlay', 'hysteria' (or 'conversion'), 'personality disorder', or 'medically unexplained symptoms' - for which the recommendation might be the ubiquitous 'CBT'! Since psychiatric diagnoses are inherently both vague and (in most cases) lacking any clear biological underpinning, it is easy to absorb any otherwise unexplained condition into a psychiatric framework. Once this is done, the patient's reports of physical symptoms tend to be invalidated, since they will be seen as (at least in part) an expression of a psychiatric condition. Symptoms may be viewed as psychosomatic, meaning 'somatic/physical symptoms created by the mind', perhaps through the discharge of emotions into the physical tissue. Whilst such processes can no doubt occur, it also seems to me that many conditions are better viewed as somato-psychic - meaning that physical health conditions have psychological effects. The concept of 'medically unexplained symptoms' tends to be taken to imply a psychological or emotional cause - when really it would be better taken in its more literal sense of there being symptoms that have not yet been adequately explained and are therefore in need of continuing enquiry and exploration.

Another condition where patients often receive a very poor deal from the NHS is that of Chronic Regional Pain Syndrome. I always feel this term is misleading, since it somehow implies a condition of pain without a real cause. In fact, it is potentially a very severely disabling condition involving progressive tissue and bone disintegration. There is a very real cause for the pain - and the condition can spread. Surgery can trigger further sites in the body of this condition. Why CRPS occurs is not well understood - but it can develop following a seemingly mild injury. I have heard of patients being given inappropriate treatment, inadequate pain relief, misdiagnosis (by psychiatrists) as 'somatoform disorder' - and being told that CBT will resolve the problem! It seems crucial that anyone unfortunate enough to suffer from CRPS should see a specialist with a good understanding of this condition.

A third condition where poor care is common is that of Lyme Disease. This is caused by bacteria of the Borellia genus, carried by ticks, which in turn are carried by deer and other animals. Human beings are infected when bitten by the infected tick - perhaps as a result of walking with bare feet or legs in areas where the ticks are prevalent, or by handling pets that have picked up a tick. The physical and mental effects of Lyme disease are widespread, multiple, and potentially devastating. Chronic fatigue, widespread pain, mood and personality changes, cognitive deficits. The UK's Health Protection Agency estimates an incidence of 2000-3000 cases per year in the UK. Many of these may be undiagnosed. Few medical facilities seem to have good understanding and resources for this illness - and, again, it seems common for people with Lyme Disease to be viewed as suffering from a psychological condition. Psychological support is important, but it is not a 'cure' and should not be regarded as the main treatment. The recommended treatment is usually prolonged use of strong antibiotics. If caught early, the disease can be eliminated. See:
NHS on Lyme disease
Lyme Disease Action
British Lyme Disease Foundation
International Lyme and Associated Diseases Society
ILADS Facebook page