Michael J Scott

  • The British Association for Behavioural and Cognitive Psychotherapy (BABCP) is the lead organisation for CBT in the UK. It has assiduously promoted the Cognitive Therapy Rating Scale and the PHQ-9, as respectively, the litmus tests of therapist competence and outcome. Students have been failed for performance on the CTRS and clinicians admonished for not demonstrating a 50% recovery rate on the PHQ -9. The two instruments have been pivotal in the giving away of CBT in routine practice for the past 18 years. But they appear to have feet of clay.

    The CTRS is only valid if a reliable diagnosis has been made. Clinicians in routine services are not trained to make a diagnosis. Thus a client may present with what looks like social anxiety, but the problem, may be avoidant personality disorder, about which the therapist is clueless. Not only are there treatment competencies, but there are also diagnostic competencies and unless the two dovetail the result is disaster. The situation is analogous to a surgeon being highly competent in knee replacements, performing one, but the problem was the patients hip! see Scott (2014) CBT Supervision. A positive screen for personality disorders predicts a poorer outcome in NHS Talking Therapies, Goddard et al (2015). The CTRS was only validated on a depressed sample, accounting for only 15% of outcome on a clinician assessment. There is no evidence that it is appropriate for use with other disorders. Nevertheless it is commonly used in CBT training for all common mental disorders.

    Lawyer holding books and court hammer in hands

    The PHQ-9 is the most widely used measure of the severity of depression. But patients are confused about whether they are being asked about the frequency of their symptoms or how bothersome they find them. Nevertheless it is the metric relied upon by NHS Talking Therapies to declare a 50% recovery rate. With clients admitted or discharged from therapy on the basis of their cut-off score (a case, is a score of 10 or more). Therapists are subjected to criticism if they do not routinely achieve a 50% recovery rate. But the measure only has a 0.48 sensitivity when studies without input by the creators of the instrument a re considered ie, of those with depression it only correctly identifies 1 in 2 of those who have depression Paniyiotou et al 2025. It is not an appropriate measuring instrument if the primary disorder is not depression, but this is routinely ignored.

    The routine use of the CTRS and PHQ-9 would struggle to stand up in a Court of law. A student failed because of his allegedly poor CTRS score and bullied over his client’s PHQ-9 scores could mount a credible case. Equally a client could claim that they were subjected to an inadequate, if common treatment, in that it failed to pass any credible test of rationality.

    Dr Mike Scott

  • Since its inception in 2008, the Service has based recovery on changes in score, on primarily the PHQ-9. With a proclaimed 50% recovery rate. The instrument, administered at each treatment session, guided treatment decisions as to whether to discharge a client or not and was usually the only feedback to GP s. But according to, a just published study in JAMA Psychiatry, the instrument has now been found to be largely invalid, with over half of patients not  properly understanding what they’re being asked. The services self-audit cannot be taken seriously.

    My own independent assessment of 90 patients, Scott (2018) using a standardised diagnostic interview suggested only a tip-of the-iceberg level of recovery.  The PHQ-9 confuses, the frequency of a symptom with how bothered the person is by the symptom. Manea et al (2017) suggest that there are researcher allegiance effects in the original validation studies. When studies conducted by those who were not instrumental in the development of the PHQ-9 were considered, the test had a sensitivity of 0.48, half that found in the allegiance studies.

    Who is responsible for the implosion? Systemic failures in Government to hold NHS Talking Therapies accountable, wishing instead to appear on the side of the angels /voters. Nobody daring to explain why £2billion a year spent on Adult and Child Services. Effectively a gift to Santa!

    Dr Mike Scott

  • Almost a quarter (22%) of young adults, aged 18-21, use AI for mental health advice, with at least two thirds (65%) of these doing so at least monthly.  A Chatbot is the ultimate in accessibility for the technologically able. This raises the question of whether we really need psychological therapists? What is the added value of routinely delivered psychological help over and above AI assisted therapy? The economic case for AI assisted therapy is clear, little or no staffing/renting costs. The burden of proof is going to rest on the coalition of private providers/University CBT courses to demonstrate their added value.  However, since their inception in 2008, they have studiously avoided independent appraisal of their wares and refused to engage in public debate. For whom the bell tolls? 

    For all ages the proportion using AI was 13%, with 92.7% of users finding the Chatbot at least somewhat helpful.

    But an article in The Guardian on November 30 revealed that chatbots offer dangerous advice to those whose mental health is vulnerable. However, the advice is better for every day hassles.

    A major problem for AI is the use of a standardised benchmark – an independently conducted standardised diagnostic interview is the ‘gold standard’ and has never been employed. But the same is also true of NHS Talking Therapies. The claimed successes cannot be trusted in either modality.

    It may be that it is only the professional bodies the British Association for Behavioural and Cognitive Psychotherapies (BABCP) and the British Psychological Society (BPS) that need them. Santa, has it seems universally distributed ChatGPT but does it meet trading standards? Probably, as much or as little as routine psychological therapy.

    McBain, R. K., Bozick, R., Diliberti, M., Zhang, L. A., Zhang, F., Burnett, A., . . . & Yu, H. (2025). Use of generative AI for mental health advice among US adolescents and young adults. JAMA Network Open, 8(11), e2542281. (Full text)

    Dr Mike Scott

  • CBT training courses represent a marriage of private providers and Universities. The latter take their lead primarily from two professional organisations, the British Association for Behavioural and Cognitive Psychotherapy (BABCP) and the British Psychological Society (BPS). Both bodies lay claim to promoting evidence-based practise. Graduates of these courses are responsible for the psychological treatment of over 1,000,000 people a year, availing themselves of public and private services. The cost to the public purse for both adult and child mental health services is £2 billion a year. 

    But there has been no independent audit of whether this money is well spent. There is no evidence that it represents an added value over and above what was in place 20 years ago. 

    The CBT training courses are tasked with enabling students to manage the translation of the randomised control trials of depression and the anxiety disorders to routine practise. But there have been no effectiveness studies conducted to act as a guarantor of this translation. The training courses have undergone ‘mission creep’, such that students are now also taught how to manage ‘complex presentations’. However, the definition of this term is ‘woolly’ and the evidence base on which treatment rests is ill-defined. There is a suspicion of exaggerated claims. I am reminded of the comedy:

    Service providers claim a 50% recovery rate based on changes on a psychometric test from the beginning to the end of treatment. But this evidence must be regarded as ‘weak’ at best: People tend to present at the worst and there is inevitably some improvement with the passage of time, “regression to the mean”. This is particularly the case if people are given attention. Additionally people do not wish to feel they’ve wasted their time and can remember their initial score, likely scoring less severely at the end of their therapeutic contact. Coupled with a desire to lease the therapist in front of them. Would they have done just as well attending the local Citizens Advice Bureau? 

    My own independent evidence Scott (2018), conducted on 90 everyday users of the Improving Access to Psychological Therapies service (the forerunner of NHS Talking Therapies) as an Expert Witness to the Court, and utilising a ‘gold standard’ diagnostic interview showed a “tip of the iceberg” level of recovery. Having reviewed further 157 litigants between 2019 and 2025 I could find no evidence in the GP records that cognitive behaviour therapy had actually been conducted. From its origins in the 1970s the hallmark of CBT has been the setting and review of homework. I have found no evidence that the ‘alleged CBT’ has happened, it would not ‘stand up in Court’. 

    To date CBT Training Courses have escaped public scrutiny, but the above considerations raise questions about their modus operandi. What is the total cost of CBT training courses? They are clearly good news for Universities, ‘bums on seats’, at a time of economic hardship. Further they extend the reach of professional bodies, validating courses and providing job opportunities for their membership. Self-interest mitigates against critical appraisal, consciously or not. 

    What effect does this have on students in the classroom? Does survival depend on toeing the party line? For example, a student re-iterating my claim of a 10% recovery rate in routine practice is likely skating on ‘thin-ice’. Too many quotes of my work and that of Dr Elizabeth Cotton is likely to incur the wrath of Course leaders. This may be followed by a ‘fishing expedition’ for misdemeanours such as use of incorrect political language and claims of poor scoring on the Cognitive Therapy Rating Scale. Protestations that the scale only has validity if the person meets diagnostic criteria for depression, is likely to be taken as further evidence of ‘awkwardness/incompetence’. This goes to the heart of whether the Universities are looking at academic freedom on CBT training courses or whether they are more concerned about budgets. What steps, if any, have Universities taken to ensure academic freedom on CBT training courses? What steps, if any have Service providers taken to ensure that students are not ‘bullied’ on CBT training courses?. Can courses evidence acceptance of a range of opinion on matters such as CBT’s superiority over other psychotherapies, the importance of formulation, the importance of diagnosis? Without this they are simply a conduit for the ‘movers and shakers’ in the professional bodies. Some students will be casualties of this oppressive culture, many others will mutter their misgivings in private. 

    Dr Mike Scott

  • I have tracked references to CBT in the records of 157 people treated either before or after a personal injury or data breach between 2019 and 2025. I found no documentary evidence of the setting of homework or of the review of homework. Yet homework has been considered the hallmark of CBT. It is difficult to escape the conclusion that what we have on offer is ‘alleged’ CBT. This applies whether treatment is conducted in primary care or secondary care, in a charity or private practice. In an earlier paper, Scott (2018) I reviewed the documentation on 90 service users. Again, there was no documentary evidence for the setting of homework. Matters have therefore not improved in recent years. 

    Service providers have utilised no integrity check on what is meeted out. There therefore can be no certainty that treating clinicians deliver what they say they deliver.

    Whilst CBT is the ‘go-to’ recommended treatment for most psychological disorders, in accordance with the NICE guidelines, its realisation is another matter.

    In the randomised control trials of CBT the setting and review of homework was a predictor of outcome. Competence has been assessed primarily using the Cognitive Therapy Rating Scale and it is the structural elements of the scale, agenda setting, setting and review of homework that were found to be the best predictors of outcome. The much-vaunted Socratic dialogue and formulation were not predictors. Yet these are a major focus of workshops. God-help the student on a CBT training course who has misgivings about the notion of formulation!

    I recently had the ‘joy’ of seeing a physiotherapist and attended with my wife. When we emerged from the 50-minute consultation we both had a different understanding of what the recommended exercises were! I anticipated that an e-mail would soon be forthcoming specifying the exercises and their manner of performance – alas! This highlighted to me that there can’t be translation from the consultation room to the real-world without a rigorous specification of actions. The professional may know very well what they intend to happen and believe it is perfectly clear, but a little anxiety on the part of the participant can muddy the waters.

    Dr Mike Scott

  • The number of cases of adult anxiety and depression has steadily increased over the past 12 years [Gkitakou et al (2025]). So, to have the number of cases of ADHD. The response of mental health professionals has been to call for greater funding of mental health. But there is sparse evidence that psychological treatment has had a significant impact on the prevalence of mental disorder – the treatment-prevalence paradox.  The UK is struggling to balance the books, on what basis should mental heath services be exempt from the axe?

    Much of routine psychological treatment is bogus.  For example, no fidelity checks have taken place in NHS Talking Therapies to ensure that therapists actually deliver the alleged CBT. There is a long history of treatments being very popular but impotent. At the turn of the millenium debriefing was in vogue, but it was found that it increased the likelihood of developing PTSD rather than decreased it, [Bisson et al (1997)].  More recently in  2014 the bestseller  ‘The Body Keeps the Score’ was published. The central claim was the trauma causes lasting neurobiological damage and that body-based treatments are uniquely effective, in that they lead to a successful processing of the trauma. Scheeringa’s (2025) review of the evidence suggests otherwise, none of them have been superior to CBT.  Nevertheless, practitioner workshops on body-based treatments abound – the power of marketing.

    Last night I attended a 3-hour workshop by Prof Popiel, from the University of Warsaw, Personalising PTSD Treatment: Self-Efficacy Focussed Cognitive Therapy. She addressed the issue what can be done if a client does not want to engage in re-living their trauma as part of PTSD treatment.  Prof Popiel has developed her own non-trauma focussed treatment and found it as efficacious as prolonged exposure. Research centres are very good at developing new treatments, but the context in which they are developed often causes translation problems for routine practice. Her protocol drew on just about every CBT strategy with rigorous stipulation of weekly homework assignments in the 10-session programme. But there was no acknowledgement that such homework assignments are nowhere to be found in routine practice. She further suggested that by assessing the temperament of the PTSD sufferer they might be better matched to the appropriate treatment. This sounds all well and good, but where is the routine practitioner going to find the time to forage in temperament scales and apply them? There was a bewildering array of forms to be completed by the client, such as thought records and material to be read. Some PTSD suffers may not have concentration problems and some may be highly educated but I rarely encounter these groups in routine practise. Doubtless they are commonplace at University Research Centres. Despite her new treatment protocol Prof Popiel remains a devotee of trauma-focused therapy for PTSD. It appears to have escaped her notice that the most plausible explanation of the equivalence of the two treatment modalities that she examined, is that to the extent that they have worked, they have altered the centrality that the PTSD sufferer has accorded to their trauma.

    Centrality is a feature of ordinary autobiographical memory, and there is no compelling reason to believe that traumatic memory is outside its’ range of application. I have detailed a centrality approach in my clinician handbook ‘Personalising Trauma Treatment: Reframing and Reimagining’ (2022) London: Routledge and my self-help book “Moving On After Trauma’ 2nd Edition London: Routledge (2024). Offering a user-friendly scaleable treatment.

    Dr Mike Scott

    Scheeringa, M. S. (2025). Evaluating evidence behind popular trauma narratives: neurobiological and treatment claims in The Body Keeps the Score. BJPsych Bulletin, 1–3. doi:10.1192/bjb.2025.10174

  • Twice in the last 2 weeks I have met trauma victims who have gone down the vortex of arrested information processing, with therapists insisting that they ‘re-live’ their trauma.

    The first client, Gwen had debility due to an accident on holiday. She complained to her therapist she couldn’t identify what was making her fearful on a daily basis, the therapist continued to insist that she could if she tried. Gwen felt the therapist was not listening, was overwhelmed by having to re-live the trauma and dropped out of treatment.

    The 2nd client Diane suffered minor disfigurement following an incident at work. She attempted suicide as a child, and the records revealed a multiplicity of labels applied to her including emotionally unstable personality disorder, borderline personality disorder, ADHD and OCD. But nowhere was there evidence of the use of a standardised diagnostic interview, to reliably identify a disorder/s. Psychological treatment had been continuous in adulthood, with a focus on repeated re-living of her trauma. Her latest diagnosis of ‘complex PTSD’ served in her mind to underline the necessity of a trauma focus. But she had not been told that this is not an accepted diagnosis in the DSM-5-TR [American Psychiatric Association (2022)]. Her psychological treatment had manifestly failed but her therapists had continued with the trauma focus. Diane was going ’round and round’ in ever decreasing therapeutic circles.

    In neither case was their documentary evidence of homework being set and review at a subsequent session. There was therefore no evidence that CBT had ever taken place. Routine practice is a ‘free for all’ – is this what the UK Government should be spending £2billion a year on for adults and children?

    It is time therapists critically appraised the arrested information processing treatment rationale. Acknowledging that it doesn’t go down well in routine practice. It is more respectful to personalise psychological treatment ‘Personalising Trauma Treatment: Reframing and Reimagining ‘ Scott (2022). London: Routledge.

    Dr Mike Scott

  • Whilst NHS Talking Therapies routinely administer psychometric tests at each therapy session, these results tell us nothing about their experience. A start could be made by using the Patient Global Impression Scale of Improvement [PGI-I Hossack and Woo (2014)], administered at the end of treatment, this asks clients to indicate how much they believed to have improved compared to before treatment using the 7 point scale below;

    1 very much better234567 very much worse

    lower scores indicating higher improvement.

    This is a real-world metric, unlike psychometric tests administered for an unreliably diagnosed disorder. But it is only a snap-shot of the person’s functioning at that point in time. It needs complementing by a standardised diagnostic interview that assesses the duration of recovery, commonly taken to mean at least 8 consecutive weeks free of the disorder.

    The scale could also be used in secondary care and private practice, where there is an almost total lack of reliable evaluation.

    Dr Mike Scott

    Hossack, T., & Woo, H. (2014). Validation of a patient reported outcome questionnaire for assessing success of endoscopic prostatectomy. Prostate international, 2(4), 182–187. https://doi.org/10.12954/PI.14066

  • This week OCD Action and survivors of the Manchester 2017 bombing have taken to BBC Television to protest about the lack of professional help available. NHS Talking Therapies boasts that it has over a million referrals a year, but the public are it seems nevertheless feeling short-changed.

    OCD Action pointed to a three fold increase in youth OCD since 2019. A survivor of the bombing was told that she had had the requisite number of therapy sessions and was now ineligible because she was out of the catchment area, for the Manchester service. Those who feel that their needs have not been met, have been led to believe that is simply a matter of demands exceeding resources. A mantra repeated by NHS Talking Therapies, in its’ quest for greater funding.

    But where is the evidence that those undergoing routine psychological treatment for OCD or a trauma response such as PTSD, recover to a greater extent than if they had attended their Citizen’s Advice Bureaux with the social consequences of their disorders. Much is made by Charities and Survivor Groups about the importance of social support, whilst nobody doubts this necessity, there is no evidence that it is sufficient to realise recovery.

    Given Government expenditure of £2 billion a year on NHS Talking Therapies for Adult and Children’s mental health, the burden of proof is on the Service to demonstrate that it does not offer a duff firework, and that its’ staff are not simply huddling around the dying embers of a fire for warmth. Perhaps eclipsed when it joins with the Department of Health and Social Care in 2027.

    Dr Mike Scott

  • The November 2025 issue of the Psychologist proclaims ‘If the NHS is to thrive over the next decade, psychology must be at its heart’. It is taken as axiomatic that psychology has a demonstrated preventative role, with a therefore assured role with the young. I might be missing something, but I could find no solid evidence base of the power of a ‘dose of prevention’. At the ‘coal-face’ I meet mental health staff bewildered at the complexity of helping needy school children. Whether to focus on the child, family or some subset and the problems of engagement. The problems are no less vexed than when I was a social worker in the 1980’s!

    Psychological wares are marketed not only for their prevention properties but also apparently for their potent intervention properties. There is some truth in the latter assertion if one points to the NICE randomised controlled trials (rcts)) for depression and the anxiety disorders. But what is meted out in routine psychological therapy bears little comparison with the protocols used in the rcts. NHS Talking Therapies has never bothered to assess the treatment integrity of the alleged CBT that it provides. My own study, Scott (2018) of 90 clients going through the system, suggests a tip of the iceberg recovery rate. A third of NHS Talking Therapy clients have only one assessment/treatment session, Scott (2024). With the haemorrhaging of a third of clients amongst those who have 2 or more treatment sessions. This can scarcely be the ‘Giving Away Psychology’ that the British Psychological Society (BPS) envisaged .

    Nevertheless BPS is ploughing on regardless, in its’ self-promotion. Calling for ever greater funding. Whither honesty? Psychology has been not so much ‘Given Away’, as a travesty of it propagandised. The idea of ‘Giving Psychology Away’ goes back to at least the 1990s, just after I became a psychologist, it is time for a more critical re-appraisal of the effectiveness of this approach. In my view it can be done, but only within some well-recognised tram lines, without them it is a juggernaut heading for oblivion.

    Dr Mike Scott