Engaging With CBT

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  • The NHS Talking Therapies: Myth

    Presentation at Annual meeting of Spanish Society of Clinical Psychology, May 31st 2026 https://youtu.be/cLIMXz4eW0A in Panel Symposium on Primary Care

    https://youtu.be/cLIMXz4eW0A

    Dr Mike Scott

  • NHS Talking Therapies – no vision for the future

    NHS England is due to be abolished and NHS Talking Therapies integrated into the Department of Health. But without any guiding vision, personalities and saving jobs is likely to be the name of the game.

    The history to date does not augur well:

    • As originally envisioned in 2008, at the setting up of the Improving Access to Psychological Therapies (IAPT) Service [the predecessor of NHS Talking Therapies] the aim [Mission] was to provide evidence-based protocols for specific disorders.
    • In 2023 IAPT became NHS Talking Therapies for depression and the anxiety disorders. Psychological therapy became talking therapy and the scope limited to depression and the anxiety disorders. [Vision obscured}
    • This has given rise to the question ‘what are the boundaries of talking therapy’, ‘is anything not talking therapy.?’ By 2026 it has become clear that the Service addresses ‘distress’ as opposed to specific psychological problems. Government is spending £2 billion a year on adult and child mental health but there is no mandate for ‘distress’ being the focus. The key Value is that those with psychological disorder are enabled to flourish, as to are the ‘enablers’. The needs of the distressed are, arguably, already catered for by the Citizen’s Advice Bureaux (CABx) addressing financial, housing needs etc. It is a waste of resources to have therapists become de facto CABX workers.

    The plot has been well and truly lost, despite over a million recipients of the Service a year. The time for a new vision is well overdue.

    Dr Mike Scott

  • NHS Talking Therapies Treats Distress Not Depression and Anxiety Disorders

    Did we really intend to create a £2billion a year service to treat ‘distress’? The gateway to its’ services have been by prospective users completing the PHQ-9 and GAD-7, measures respectively of the severity of depression and generalised anxiety disorders. With three quarters of people identified as ‘cases’ of either using established cut-offs, Vos et al (2026). These authors recommend instead the use of the CORE-10 a measure of general distress, which produces a caseness level of 87.3%, ensuring that all are casualties and presumably in need of treatment. The corresponding proportions for caseness for the PHQ-9 and GAD-7 were respectively 71.0% and 74.8%. It is doubtful that the measures are meaningfully distinguishing amongst each other.

    NHS Talking Therapies boasts NICE compliance. But the latter make no recommendations on ‘distress’ how then can the National Service be compliant? Let us be honest the Service does whatever its clinician’s fancy. It is scarcely credible that this randomness can usher in real-world changes in the lives of clients.

    Levis et al (2019) found half the depression cases identified using the PHQ-9 were actually misdiagnosed. What a waste of treatment efforts. If you wanted to set up a wasteful treatment Service NHS Talking Therapies fits the bill perfectly. But no hint of this in the missives of the annual gathering of the British Association of Behavioural and Cognitive Psychotherapists (BABCP) in mid-July. However this Saturday May 31st, in a presentation titled ‘All Talk and No Action’ to be given at the annual meeting of the Spanish Society for Clinical Psychology I will give voice to such concerns.

    Dr Mike Scott

  • What is the Best Explanation of NHS Talking Therapies Massive Database?

    The Service solicits questionnaire results from each client at every therapy session. With over a million clients a year and an average of seven treatment sessions per client for completers, that’s a massive amount of data. But to paraphrase Coleridge’s Ancient Mariner, ‘NHS Talking Therapies data everywhere and not a drop to drink’. 

    Talking Therapies proclaims that the data reveal a 50% recovery rate, comparable to that in randomised controlled trials of CBT for depression and anxiety disorders. The UK Government’s Office for National Statistics (ONS 2024) has stated that there are not only health benefits but that the NHS Talking Therapies treatment has led to an increase in income and reduced unemployment. However, the government’s National Audit Office (NAO) has been strangely silent on whether the Service is value for money.

    But it is not possible to discern the operation of any plan in NHS Talking Therapies ministrations. There is no documentary evidence of the setting and review of homework at each therapy session. Given that CBT is distinguished from other psychological treatments by its psycho-educational nature, there is considerable doubt that CBT has in fact been administered. The National Institute for Health and Clinical Excellence (NICE) guidelines state that evidence -based-treatment should be diagnosis specific, but the service clinicians are not trained to diagnose. The meaning of the data collected is therefore opaque. Though the data collected has grown exponentially since the inception of the Service in 2008, it is no more valid than it was at the beginning. But the ONS’s conclusions assume that the NHS Talking Therapies proclaimed narrative is true. Without this solid foundation their assertion of positive economic effects crumbles. 

    What NHS Talking Therapies clinicians actually do is to ‘tinker’, CBT sounding phrases abound, but it is ‘All Talk and No Action’, with no evidence of the dovetailing of treatment targets with matching treatment strategies. There has been no independent assessment of treatment integrity. The Service asserts that its’ clinician’s interventions are guided by their formulations, but there is no evidence of the reliability of these plans/formulations. There is no evidence of intelligent design behind the Service. Unsurprisingly the response of a third clients is ‘thanks, but no thanks’ [ Scott (2025)], attending only one assessment/treatment session. For every ‘decliner’ two people attend two or more treatment sessions. 

    Tellingly the diagnostic status of NHS Talking Therapies clients has never been assessed independently by a publicly funded body using a standardised diagnostic interview. The duration of ‘recovery’ has never been assessed – psychometric tests only give a snapshot picture of the client at a particular point in time. Clients wish for real-world recovery not to be ‘tinkered’ with. My own study [Scott (2018)n] of NHS Talking Therapy clients showed only a tip of the iceberg recovery rate.

    Dr Mike Scott

  • An Explosion of Treatment Manuals

    There has been an exponential increase in the number of treatment manuals since the 1970’s. But only 13% are cited in treatment guidelines such as NICE. Further there is no evidence that these tomes have made a difference to routine practice.

    NHS Talking Therapies swears allegiance to NICE Guidelines, but documentary evidence of compliance with the Guidelines has been conspicuously, totally absent in the 200+ cases I have reviewed. This is the subject matter of my Keynote address to the Spanish Society of Clinical Psychology on May 30th 2026, ‘All Talk and No Action’.

    Initially the treatment manuals were all diagnosis specific. But in recent decades they have been increasingly transdiagnostic. The new conventional wisdom has been that manuals are the ‘problem’, perpetuating the idea of diagnosis. But this position is no longer tenable. Flexibility without fidelity has become the new norm, with idiosyncratic formulation ruling. Making a formulation ‘stick’ depends on a person’s position in the hierarchy, with academic clinicians running CBT courses at the top, marketing themselves with ever more manuals.There has been no independent audit of the legacy of these manuals at the coal-face.

    Dr Mike Scott

  • Beyond NHS Talking Therapies Data Points

    ‘I’m just a number”, a common response of individuals treated badly by their employer. But the ‘bread and butter’ of AI and NHS Talking Therapies is data points. Just as an employee might protest that they are more than a unit of production, so to clients may protest about a reduction of their experiences to a score on a questionnaire they completed.

    NHS Talking Therapies boasts more than a million clients a year, with questionnaires completed on each after every session. There is no doubt that they have accrued voluminous data. But the data does not speak for itself. A score on a questionnaire has no intrinsic meaning. Multiplying the number of questionnaires completed provides no added evidence of anything.

    It is possible to treat the results of trained clinicians as a ‘gold standard’ against which to assess the performance of Chatbots. But the vetting procedures for the ‘gold standard’ needs to be robust. There has been no independent evidence that what trained clinicians generally do makes a ‘real-world’ difference. A consensus judgement about ‘good practice’ is not evidence. As in a Court of law, evidence must be based on multiple independent assessments and a variety of information sources. In lieu of a reliable database, appeal is made to the results of randomised controlled for depression and the anxiety disorders. But this is to ‘impersonate ‘ the rcts, the latter had independent assessments of the diagnostic status of clients before and after treatment and follow-up. Comparability of effectiveness with the rcts is a ‘con’.

    It is quite possible that Chatbots do just as well or badly with sufferers from anxiety/depression as NHS Talking Therapies. But this is because of the employment of metrics of convenience, rather than validity. The irony is that this could be seen as a cost-saving way of eliminating at least low-intensity therapy. The Service has backed itself into a corner, hoisted by its’ own petard.

    Dr Mike Scott

  • NHS England and Fraud

    NHS England has continued to use a metric of recovery for those undergoing its’ Talking Therapy service that is known to be invalid. This costs the British taxpayer about £2 billion a year. It boasts a 50% recovery rate. The primary metric used is the PHQ-9, an alleged measure of the severity of depression, with a cut-off of 10 or more used to designate a case of depression.

    Recently Hlynsson et al published a paper titled ‘Why are we still using the PHQ-9?‘ they observed fundamental problems:

    • a confusion about whether the instrument is measuring the frequency of a symptom or how bothersome it is
    • because of this confusion clients can respond differently on separate occasions and this does not necessarily reflect a change in symptomatology
    • false positive rates often exceed 50%
    • The PHQ-9 uses a two-week time frame but it is administered at every session in NHS Talking Therapies, which are often weekly. The instrument has not been validated for use in this way
    • ‘there is a need for greater transparency and independent evaluation of assessment t. ools’

    The PHQ-9 is at best a measure of the severity of depression, it is nonsense to use it as a yardstick for every disorder that presents to NHS Talking Therapies. This echoes the findings of Panayotiou et al 2026 ‘this study identified widespread misinterpretation of the PHQ instructions across community and clinical samples, raising doubts about its validity for both research and clinical decision-making’.

    The PHQ-9 had its’ origins in Pfizer’s marketing of a drug, 20 years on it’s the mainstay of NHS England’s marketing.

    A client could make a claim that NHS Talking Therapies has not discharged their duty of care to them by relying on a dubious diagnostic instrument and navigating treatment accordingly. Their plea in mitigation that the Service doesn’t make diagnoses, rings hollow.

    Dr Mike Scott

  • Talking Therapy Is a Myth

    Talking therapy was commoditised in 2023 when the Improving Access to Psychological Therapies (IAPT ) Service was re-branded NHS Talking Therapies. But it has not been possible to discern an added value of the latter over the former. The term is a ‘fuzzy’, and unsurprisingly therefore, there has never been an independent evaluation of ‘talking therapy’. For marketing purposes the term is equated with ‘psychological therapies’, but the latter are qualitatively different. Psychological therapies refers to disorder specific protocols. But neither NHSTalking Therapies or its’ predecessor make diagnoses. Further ‘psychological therapies’ employ measures of treatment fidelity, the latter are conspicuously absent in NHS Talking Therapies offerings. In summary, Talking Therapy is a ‘con’, costing the UK taxpayer about £ 2billion a year for Adult and Child Mental Health Services,

    Psychobabble – to speak this language just repeat without explanation: ‘my formulation is…..’, ‘your score on the test probably indicates you suffer from anxiety/depression’, ‘you had bad childhood experiences that you have probably not worked through’, ‘you have not properly processed X’, ‘you are best put on the ADHD/ASD pathway’, ‘we provide trauma-informed care’, ‘we provide evidence-based treatment’. If challenged refer to your years of experience and/or ‘my clinical judgement’ and that you deliver ‘accepted best practice’. These statements rarely withstand cross-examination, yet are taken for granted in CBT circles. Departing from them on CBT courses is professional suicide. They are open to challenge along 3 axes:

    validity – how true is this?

    utility – how useful has this proven to be?

    authority – who says this is true?

    Career progression depends on fluency in psychobabble, a prime focus in many workshops.

    Dr Mike Scott

  • The Trivialization of Mental Health and AI Fodder

    In England as a whole there are twice as many low intensity therapy sessions as high intensity sessions. But there are staggering local variations. In my own neck of the woods in Cheshire and Merseyside there are 8 low intensity sessions for 1 high intensity session. It is difficult to believe that my fellow-Scousers are so resilient that they rarely need to avail themselves of high intensity treatment. [ the data for all 40 Integrated Care Boards, ICBOs, can be found using this link, courtesy of Paul Atkinson https://x.com/paulananke/status/2004513683251286505?s=46]

    The Cheshire and Merseyside Integrated Care Board Talking service offer online talking therapy via the text based digital service leso and the digital service Silver Cloud. Psychological well-being practitioners staff the gateway to NHS Talking Therapies. These are the least qualified staff and it seems likely that they find what they’re looking for, that is problems which fall within their competence, and which they believe they have the competence to address. Resulting in a skewed profile. They’re not taught to make reliable diagnoses. This results in a trivialization of client’s mental health problems, which suggests that they are an appropriate target for AI therapy. This is likely to be warmly welcomed by the developers of the Chatbots and service providers. Redundancy around the corner. Professional bodies such as BPS and BABCP need to “smell the coffee”, But there is no sign of them doing so anytime soon.

    The American Journal of Psychotherapy has just published a pilot study of a comparison between an artificial intelligence therapist and a human therapist in delivering text based cognitive behavioural therapy. Outcome was judged on the cognitive therapy rating scale and not by recovery from any disorder. The authors suggest that it may complement human-based therapy. The real-world has it seem receded.

    Dr Mike Scott

  • The Reification and Destruction of Cognitive Behaviour Therapies Twin Towers

    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