Are Mental Health Professionals Crooks?
This quote is from Therapy Today, the magazine of the British Association of Counsellors and Psychotherapists. ‘According to a recent Government research summary, the more vulnerable children and young people have experienced worsening mental health throughout the pandemic, particularly during the lockdowns….The impact is highly variable, with different surveys finding conflicting results on the relative incidence of depression and anxiety, PTSD and behavioural issues. However, what is incontrovertible is that the overall rate of mental disorder rose from one in nine pre-pandemic to one in six in 2020’.[1] It was written by a very experienced journalist, who specialises in mental health and who was for many years the editor of the magazine, which is the official publication of the largest representative body for therapists in the UK, with a membership of more than 50,000 and that conclusion is a little loose.
The ‘one in nine’ statistic comes from the NHS Mental Health of Children and Young People survey 2017.[2] The ‘one in six’ statistic comes from the 2020 Wave 1 follow up to the 2017 survey[3] and there are problems with comparing the two. 2020 involved a much smaller sample – about a third of the size of the 2017 survey. The 2020 follow up included a series of questions about life during Covid, lockdown, missed schooling and effect on family, which obviously weren’t part of the previous surveys. The inclusion of that additional Covid specific material introduces some risk of ‘leading’: participants unconsciously responding to the ‘demand characteristics’ of questionnaires is a well-known problem.
There are also problems with the nature of the conclusion which is being attempted to be drawn here. Statistics about the prevalence of mental disorder from the 2017 (and the previous MHCYP surveys) came from clinical assessments, using recognised diagnostic tools and included face to face interviews. 2020 relied solely on online submission of a brief behavioural screening questionnaire, which is primarily used in education (not for clinical purposes). The comparison points between 2017 and 2020 in the 2020 report only involved data from that brief behavioural screening questionnaire, so we are comparing like for like, but the screening questionnaire isn’t a diagnostic tool. It doesn’t map against clinical diagnoses because that’s not what it was designed for and when its predictive power in respect of mental illness has bene tested, it’s has been found to be weak for a number of different disorders.[4] Particularly (as here with no input from teachers in 2020, although though there was in 2017), where the data is compiled from limited information sources.[5] So, things may have shifted between 2017 and 2020 but there isn’t actually a very good basis for saying that the result has been an increase in mental disorders. And saying there’s been a 30% increase in mental disorders amongst children is a very powerful statement to make.
And there are problems with the way the results of the 2020 survey were presented. The increase from one in nine to one in six is the headline statistic, and got all the attention, but the results actually involved three categories: ‘unlikely to have a disorder’, ‘possible disorder’ and ‘probable disorder’. Whilst the levels of reported probable disorder increased between 2017 and 2019 (11 % to 16%), the rates of possible disorder actually fell, from 15% to 10%. The result is that overall the levels of children whose mental health gave cause for concern, and those whose didn’t, remained the same between 2017 and 2020 (25:75 in 2017 and 24:76 in 2020). That’s a rather different picture to the one painted by the article.
So, it is controvertible that ‘the overall rate of mental disorder rose from one in nine to one in six’. There is barely a statistic about mental health that isn’t controvertible but this one has got quite a lot of holes in it. What’s more, selective use of that one in six figure on its own, is capable of giving a quite misleading impression about what happened between 2017 and 2020.
And it was always going to be a dubious decision to insert the short form Wave 1 update into the MHCYP series. A large part of the value of the MHCYP, which has been running every seven years since 1999, is precisely that it has allowed comparison between statistics obtained using the same methods over 20 years. So, this was all we needed – an inconsistent basis of measurement pitched into one of the few areas of relative clarity in the whole incoherent mass of evidence on mental health.
Particularly as you might have expected the shift to greater degrees of self-report involved in the 2020 survey to produce increased levels of concern about mental health. It’s well-known that surveys relying on self-report tend to show higher incidence of mental health issues than research involving questionnaires or clinical assessment – people seem to have become increasingly ready to believe they have a mental health problem when established clinical tests suggest they don’t. One 2018 study led out of UCL reviewed surveys involving more than 140,000 participants and found dramatic increases in the incidence of self/parent reported mental health conditions amongst children and young people over the last two decades (a six times increase in England) but no significant change in psychological distress or emotional well-being using recognised questionnaires and assessments.[6]
The 2020 follow up might be explained as a well-meaning but clumsy attempt to get an interim snapshot of data in response to extraordinary times (which had never been felt necessary before) - but it still had the effect of increasing the reported scale of the problem and, so, boosting the funding credentials of the mental healthcare community.
Sometimes the presentation of information about mental health by mental healthcare professionals is harder to explain away. The NHS releases performance figures for its Improving Access to Psychological Therapies programme. Each year they suggest recovery rates of around 50% - this is the language used from the latest report: ‘51.4% referrals moved to recovery up 0.3 percentage points from 51.1% in 2019-20’.[7] 50% is not a great result but it is what it is and there’s quite a lot of respectable physical medicine we wouldn’t question that achieves recovery rates around 50%. But what you wouldn’t expect is that when they say ‘referrals’ they don’t actually mean referrals, they mean patients who complete a course of therapy. About half the patients who start therapy don’t complete the course. So, in fact, IAPT results suggest therapy only works with around a quarter of the people who get it.
There were 1.46m referrals to IAPT in 2020 to 2021. When you hear that 51.4% of referrals moved to recovery, it would be very easy to imagine that therapy through IAPT helped more than 700,000 people recover from a mental health condition last year. In fact, around 30% of referrals never get to therapy, so that’s about a million who start. Of those, about half drop out and about half the balance get to recovery – so about 250,00, from 1.46m.[8] That’s not looking quite so promising and it presents a rather different case for investment.
At best, saying ‘51.4% referrals moved to recovery’ is extremely disingenuous. It’s comparable to the recent controversy over NHS figures showing that nearly 100,00 patients waited more than 12 hours in A&E last year. 100,000 waiting more than 12 hours in A&E is pretty shocking but, once it emerged that these figures only included people after a decision had been taken to admit them, the NHS was forced to produce revised figures showing that the real figure for people who had to wait more than 12 hours after arrival in A&E was nearly 1m.[9] That’s really quite breath-taking sleight of hand.
The legal definitions of fraud revolve around obtaining something dishonestly and dishonesty involves deliberately or recklessly misleading people. Recklessly includes not caring enough whether what you’re saying is true and it’s always been a very important element of fraud because the most effective con artists are the ones who manage to believe themselves. These basic elements of fraud are supplemented in various specific situations. So, for example, section 90 of the Financial Services Act 2012 makes it a criminal offence to do anything which creates a false or misleading impression as to the value of investments, with a defence available if you can show you reasonably believed you weren’t going to create a false or misleading impression.
Psych (right across the piece - psychiatry, psychology, psychotherapy and neuroscience) is not very careful with what it says about mental health. The media is saturated with emphatic statements about mental health, by commentators and mental health professionals; you come across them all the time. They might be statements about the causes or mechanisms of mental illness, its prevalence, or the effectiveness of treatment methods; it doesn’t really matter. To help put these kind of statements – any statements, really, that make confident assertions of knowledge about mental health - into perspective, a systematic review carried out of the University of Groningen in the Netherlands earlier this year decided that ‘there is no convincing evidence that interventions for the most common childhood disorders are beneficial in the long term’.[10]
That’s a remarkable thing to say: most mental health professionals would accept that in some form most mental health issues have their roots in childhood – childhood is where the problems start - but this is saying that there is no good evidence that anything we’re doing with children will make any difference to their mental health later in life.
All that unhappiness and suffering, all those hospitals and clinics, all that research and we don’t have any proof that what we’re doing works – ‘the scientific literature cannot answer the important policy and health care question regarding the long-term effectiveness and safety of treatment of childhood mental disorders with any confidence’.[11]
If you send your child for professional help – and apparently 400,000 children a month are being treated though the NHS Child and Adolescent Mental Health Service,[12] which has increased its staff by 50% over five years,[13] and that’s just children seen within the NHS – there is no evidence that it’ll do any good in the long term. Wow!
A popular technique for Psych to sound credible is to lean on its harder edged, more science-based elements. Therapists with no training or expertise in physiological science will drop in references to neuroscience, casually as if they were just touching on the tip of the iceberg of their knowledge. Bookshop shelves are stacked with self-help guides claiming to be based on the latest, cutting-edge neuroscience.
This is all illusory and it’s very misleading. Neuroscience has not made a single meaningful contribution to mental healthcare - as things stand, neuroscience can’t tell us anything practical about what makes people ill or how to make them well. This quote is from a paper earlier this year, co-authored by the professor of neuropsychiatry at UCL and founding director of the Welcome Trust Centre for Human Neuroimaging: ‘despite three decades of intense neuroimaging research, we still lack a neurobiological account for any psychiatric condition. Likewise, functional neuroimaging plays no role in clinical decision making’.[14] No role in clinical decision making…what about all those articles on 5 ways to enlist your brain to live a better life?
It’s a similar story with genetics – this quote is from a book earlier this year by Thomas Insel, ex-director of the National Institute of Mental Health (America’s psychiatrist-in-chief): ‘at the current state of the science, its difficult to point at anything coming from psychiatric genomics that is ready for clinical use in diagnosis or treatment.’[15] There’s nothing there either; genetics hasn’t given us anything we can use.
These statements stand out precisely because they are so unusual: generally, Psych has been very happy to allow a very different impression to be created about what science has been able to tell us about mental health. But bankers, brokers, lawyers, accountants and people running public companies can go to prison if they do anything which creates a false or misleading impression as to the value of their products.
It’s true that, by and large, mental health professionals aren’t trying to make off with very large sums of money, and they’re not trying to take advantage of individual investors who are putting their money at risk. But this is still how these people make their money and buy their cars and go on holiday and eat in restaurants. In some ways the situation is worse: unlike investors, we don’t have a choice here, we’re all paying for this through our tax bill and, with the NHS spend on mental health estimated at around £15bn a year,[16] the sums involved can dwarf anything going on in the City.
So, of course it is different to deliberate fraud, but does it seem so outlandish to question whether something a little crooked is going on when Psych makes such conspicuously little effort to abide by the standards we enforce against the finance industry, retailers of washing machines, advertisers and just about every other walk of life that involves doing something and getting paid for it?
[1] https://www.bacp.co.uk/bacp-journals/therapy-today/2022/april-2022/the-big-issue/
[2] https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017
[3] https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2020-wave-1-follow-up
[4] https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/using-the-strengths-and-difficulties-questionnaire-sdq-to-screen-for-child-psychiatric-disorders-in-a-community-sample/77B6D9AB0A02DF2455847634A704F1C5
[5] https://files.digital.nhs.uk/D1/D411D3/mhcyp_2020_meth.pdf
[6] https://www.cambridge.org/core/services/aop-cambridge-core/content/view/AB71DE760C0027EDC5F5CF0AF507FD1B/S0033291718001757a.pdf/div-class-title-mental-health-and-well-being-trends-among-children-and-young-people-in-the-uk-1995-2014-analysis-of-repeated-cross-sectional-national-health-surveys-div.pdf
[7] https://digital.nhs.uk/data-and-information/publications/statistical/psychological-therapies-annual-reports-on-the-use-of-iapt-services/annual-report-2020-21
[8] https://therapymeetsnumbers.com/iapt-2018-why-do-less-than-1-in-5-referrals-reach-recovery/
[9] https://www.telegraph.co.uk/news/2022/08/25/nhs-misled-public-growing-crisis-ae-waiting-times/
[10] https://acamh.onlinelibrary.wiley.com/doi/10.1111/jcpp.13677
[11] Ibid
[12] https://www.centreformentalhealth.org.uk/blogs/childrens-mental-health-services-data-behind-headlines
[13] https://www.healthcareconferencesuk.co.uk/news/2022-5-24/record-high-number-of-children-treated-for-mental-health-problems-in-uk
[14] https://www.sciencedirect.com/science/article/abs/pii/S089662732200647X
[15] https://www.amazon.co.uk/Healing-Path-Mental-Illness-Health/dp/0593298047?ref_=nav_custrec_signin
[16] https://www.england.nhs.uk/mental-health/taskforce/imp/mh-dashboard/