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