Michael J Scott

  • NHS Talking Therapies claims to be, not only NICE compliant, but to achieve comparable results. But the unit of analysis in the trials that NICE relies on, as the foundation for its’ recommendations, is recovery from a disorder assessed by an independent assessor, using a standardised diagnostic interview. By contrast,  in NHS Talking Therapies the unit of analysis is change in score on psychometric test/s. These differences in the units of analysis make comparisons meaningless – a  comparison of ‘apples and pears’. It is rather like being asked which is the greater, 50 kilogrammes or 50 metres? The units of analysis have different dimensions. No amount of strident, charismatic claims by NHS Talking Therapies can square this circle.

    Nevertheless, Government bodies and Service providers are prone to believing what they want to believe, ‘all is basically well in the delivery of psychological therapy, all that is needed is more funds. So that ministrations can be extended to other populations such as those with long-term physical conditions, chronic fatigue, ADHD and autism’. Who are the attendees at the Mad Hatter’s Tea Party?.

    The National Institute of Health and Care Excellence (NICE) recommends different psychological therapies for specific types of anxiety and depression. The table below is a summary of the recommendations, taken from the NHS Talking Therapies Manual published at The NHS Talking Therapies Therapies Manual 2023-2024.

    But there is no evidence of parity between the recommended treatments.  Nor of the evidence base on which they rest. The table above would suggest, for example, that the evidence base for CBT for chronic fatigue, is comparable to that of CBT for depression. Further that the evidence base for computer assisted guided self-help is comparable to that for CBT for depression. It suggests each of these treatments are ‘winners’ and must have prizes. But it’s unlikely that this is the interpretation NICE intended. Unwittingly NICE has compounded the problem by not specifying the studies it was relying upon with regards to specific disorders. NHS talking therapy have been able to drive a ‘horse and cart’ through NICE recommendations.

    Dr Mike Scott

  • On Wednesday the BBC morning News featured a Southampton University student, Hamish, who, as a result of sepsis, lost his four limbs. Amazingly he’s back driving, walking and continuing his philosophy degree. Hamish is living proof that is not the trauma per se that is important but what it is taken to mean for today. Earlier in the week, on ITV, I watched an episode of ‘Long Lost Families’ which featured an unsupported Mum, who as a 15-16 year old gave her 6-month old son up for adoption. The experience had clearly been absolutely devastating for her, but the programme reunited them both. The good news for her was that it had been a good adoption. However, at aged 12 or 13 her son found out that he had been adopted. His world was turned upside down as he viewed his life to that point as having been a ‘fiction’. He became estranged from his adoptive parents and they were devastated, with no appreciation of what had brought about the sharp change in him. This served to underline that is the take on events that is pivotal for outcome, rather than the trauma itself. We are all engaged in mental time travel, going back and forth in our ‘Dr Who, Tardis” collecting items from the past and gauging their utility for today.

    But clinicians are often hi-jacked by the drama of the event and not the unfolding story, unnecessarily distressing themselves and their client, with a ‘re-living’ focus.  A recent paper by Zoellner et al (2025) suggest that clinicians have overestimated the importance of the trauma and have underestimated the significance of the re-framing processes that occur subsequently. In my self-help book Moving on After Trauma Routledge 2024 and Clinician Handbook Personalising Trauma Treatment: Re-framing and Re-imagining Routledge 2022, I have proposed that it is the centrality accorded to the trauma that is significant and this is where therapeutic efforts need to be targeted. This is a radical departure from the traditional trauma focused treatment. The beauty of a centrality approach is that it is applicable not only to extreme trauma but also to lessor stressors such as bullying at work or being a victim of a Data Breach.

    Dr Mike Scott

  • The good news is that the Service is having a Workshop, in December, for Psychological Wellbeing Practitioners, ‘Improving Engagement and Recovery’, the bad news is that it suggests the haemorrhaging [see previous post] can be treated by PWPs learning from each other. Inspection of the day’s programme, suggests that there is no evidence-base for the emerging recommendations. Rather they are the received-wisdom of the ‘movers and shakers’ amongst PWPs. One is reminded that ‘turkeys do not vote f or Christmas’, and similarly, PWP’s are unlikely to countenance that their modus operandi is fundamentally flawed.

    The Service will be integrated into the Department of Health and Social Care, but there is no hurry to do this.The Department will likely focus on operational matters, such as redundancies and cost-savings and it is unlikely to consider whether the Service for adults is worth the £1 billion a year spent on it.

    Clinicians who are not PWPs, likely have serious misgivings over their operation, but dare not put their head above the parapet. This week a clinician in secondary care told me of a PWP who had administered the PHQ-9, the score was high because the client had been bereaved, the PWP asked the client to complete the test ‘as if they had not been bereaved’ – so much for the claimed reliable data set.

    Dr Mike Scott

  • Only a third (37%) of those engaging in NHS Talking Therapies completed treatment in 2023/2024, with 17% of these designated as ‘reliably recovered’, according to data analysed by Bagri (2024) of the Nuffield Trust. But the Attrition issue was neither acknowledged or addressed at the recent European Association for Cognitive and Behavioural Psychotherapies (EABCT) Conference, held at the University of Glasgow, in September 2025. Instead, the Service’s prime mover [Clark (2025)] re-iterated the Services’, implausible claim of a 50% recovery rate, amongst those who attend 2 or more treatment sessions, adding that the Service was ‘spectacular’. Yet he did acknowledge that there has never been a randomised controlled trial of the effectiveness of NHS Talking Therapies, which alone would provide a definitive answer on effectiveness in routine practice. Puzzling – it seems strangely reminiscent of the TV comedy ‘Never Mind the Quality, Feel the Width’.

    My own independent study, conducted as an Expert Witness to the Court, suggested only a tip-of the iceberg recovery rate, Scott (2018). With recovery defined, not by a psychometric test score, but on the basis of a reliable standardised diagnostic interview – the ‘gold standard’ in randomised controlled trials.

    Low-intensity treatments accounted for 39% of all appointments [ Bagri (2024))], in 2023/24 including guided self-help and computer assisted CBT. But the evidence-base for these cheaper options is weak by comparison with high-intensity interventions. On what basis can the low intensity treatments be said to clear a ‘good enough’ threshold?

    In 2023/24, a third (34%) of appointments were for CBT, Bagri (2024). The evidence base on which the other two thirds of appointments rest is lacking. With a fifth of appointments dedicated to psychoeducation, physical activity and employment support. But the Service has no expertise in these areas and was not set up originally to deliver them. The Citizen’ s Advice Bureaux is likely better placed to deliver in these domains. NHS Talking Therapies has suffered from ‘mission creep’, most recently targeting those with long-term physical conditions.

    At the front door of NHS Talking Therapies in 2023/24, 20% of referrals were declared unsuitable. This is a great waste of resources but the basis for declaring ‘unsuitability’ is opaque. The decision is made by the gatekeeper, a Psychological Wellbeing Practitioner (PWP), the least qualified of all staff and not a therapist, sometimes in consultation with his/her Supervisor.

    In a paper delivered by Dr Cotton to the British Sociological Association on August, 26th 2021 she claimed that 41% of those working for NHS Talking Therapies predecessor, IAPT had been asked to manipulate data about patient’s progress’ . Unsurprisingly, annual staff turnover in NHS Talking Therapies is 18%, whilst 68.6% of PWPs report burnout Westwood (2017).

    Bagri, S (2024) “Does the NHS Talking Therapies service have an attrition problem?” Quality Watch: Nuffield Trust and Health Foundation.

    Clark (2025) Developments in England’s NHS talking therapies for anxiety and depression: data availability and analysis. Paper delivered at the University of Glasgow, EABCT meeting, September 5th 2025.

    Dr Mike Scott

  • It is, as if NHS Talking Therapies is housed in a Georgian townhouse. It is not fit for those with a ‘mental disability’. Following a telephone conversation, with a receptionist, you may arrive at the address at the appointed time, only to find your path is barred by a series of steps. Given your lack of ‘mobility’ you may elect to go home. A third of people (33.1%) did that in the year ending March 2025. NHS Talking Therapies Annual Report.

    Once inside, you are greeted by a receptionist who clerks you in, takes your biographic details and gives you two questionnaires to complete. The PHQ-9, a measure of the severity of depression and the GAD-7, a measure of the severity of anxiety. The receptionist might decide that you are not suitable for the service because of your drinking or alternatively that because you are suffering from PTSD/social anxiety disorder/body dysmorphic disorder, you should go straight to the 1st floor where the High Intensity Therapists are housed. Low intensity CBT therapists occupy the ground floor, offering usually up to 6 sessions.

    Almost half of those who enter the building (43.8%) do not complete treatment (defined by the Service as attending 2 or more sessions) according to the latest NHS Talking Therapies for anxiety and depression Annual Report (September 2025).

    Arbitrary Signposting and Treatment

    But there is no transparency about the receptionist’s directions, no specification as to how much drinking is acceptable nor the criteria used to decide on PTSD, body dysmorphic disorder or social anxiety disorder. The receptionist’s lanyard may tell you that he/she is a Psychological Wellbeing Practitioner (PWP) or en route to be a PWP. A brief search on Google reveals that PWP’s are not trained therapists. The PWP has power but lacks credentials.

    The NHS Talking Therapies clinicians are not trained in diagnosis, but the doors on both floors each bear the label of a disorder.  The myth is that behind each door a therapist is compliant with delivering the designated disorder. But no fidelity checks have ever been conducted.

    If initial ministrations are deemed unsuccessful (PHQ-9 or GAD-7 scores above the thresholds of 10 and 8 at the end of treatment) they are sent upstairs to the Hi-intensity therapists. About 10% of clients climb the stairs to the 1st floor but this climb typically takes weeks. 

    Thanks, But No Thanks

    In 2022-2023, for the most common disorders depression and GAD almost as many people attended just one session 235,701 as attended two or more sessions 442,792. Scott (2024).

    The one session attenders appear no different to those who attend two or more sessions, based on psychometric test scores. Yet the former are half as numerous as the latter, but have been ignored by the Services researchers. I had to get details on them from a Freedom of Information request Scott (2024).

    The building is not fit for purpose. But the rent costs about £1 billion a year, with similar expenditure for the nearby Child and Adolescent Mental Health building. A radical re-think is necessary, but the NHS Talking Therapies juggernaut shows no signs of pausing, might this change when it becomes part of the Department of Health?

    Dr Mike Scott

  • The Service was set up to address cases of depression and anxiety,  with a mirroring of treatment for these disorders in the CBT randomised controlled trials (RCTs). In the RCT’s there was an average recovery rate of 50%. But these trials excluded patients with a personality disorder. Given that personality disordered clients are commonplace in NHS Talking Therapies, it is scarcely credible that the Service should achieve a claimed comparable recovery rate.

    In a representative sample of IAPT clients, Hepgul et al (2016) found that 69% had a high risk for a personality disorder with 16% meeting criteria for borderline personality disorder. However, NHS Talking Therapy clinicians do not have the skills to either identify or treat personality disordered clients. Their clinicians literally do not know what they are dealing with.

    Stepped-Care More Apparent Than Real

    The intent was that NHS Talking Therapies would focus on straightforward cases of anxiety and depression, with severe pathology: personality disorders, bipolar and psychosis, managed by secondary care. But it hasn’t quite worked out that way. As many as 35% of IAPT clients (the predecessor of NHS Talking Therapies) exhibit clinically significant psychotic experiences [Perez et al (2017) and 61% scoring above the screening threshold for bipolar disorder Knight et al (2020). Those scoring highly on a Psychotic Experience scale had a lower recovery rate. But NHS Talking Therapie’s gatekeepers, Psychological Wellbeing Practitioners do not have the skills to identify, much less treat severe mental illness.

    Within NHS Talking Therapies cases of PTSD, social anxiety disorder and body dysmorphic disorder are supposed to bypass low intensity and go straight to high intensity. But this presupposes that the PWPs can reliably identify them. However there is nothing in their typically 45 minutes telephone assessment that is a guarantor of reliable assessment of these, or indeed any disorder. The stepping up is again more apparent than real.

    In mental health, stepped care is an attempted replication of what occurs in physical health, where therapeutic resources are maximised by using the least costly intervention first, proceeding to more invasive/costly intervention if the cheaper option does not work. But in physical health there is more reliable diagnoses.Whereas in routine mental health scarce attention is given to diagnosis and for many practitioners it is anathema. With no agreement on what ‘works’, it is welcome to ‘Bedlam’.

    Zavlis (2023) has observed:

    ‘UK national data suggest that: (1) of the 1,647,716 IAPT referrals in 2019/20, 63.21% did not complete treatment and (2) of those who completed treatment, around 60% did not achieve clinical recovery. [ Using the Service’s own metric – my Comment] Although speculative, it may not be farfetched to assume that many such cases of treatment resistance are due to comorbid personality difficulties (among other comorbidities, of course)’.

    Complexity Bias

    The ‘get out of jail card’ for psychological therapists is that their client is ‘complex’. Service providers too, can easily appeal to ‘complexity’ to cover poor performance. ‘Complexity’ has become a selling point for workshops and books. However it is chameleon-like, with no agreed and consistently applied definition. The American Psychiatric Association has, in my view, rightly refused to recognise ‘complex PTSD’. A complexity bias operates in UK mental health:

    Starting in 2009 I wrote a trilogy of books under the ‘Simply Effective’ title published by Routledge. The starting point was simple, an open-ended interview in which the client has the space to tell their story. Followed by questions about each of the symptoms that comprised, possible diagnoses. With treatment targets pertinent to the diagnoses and matching treatment strategies. It was the antidote to ‘Complexity’ and the ‘complexity bias’, involving Sat Nav’s for the 10 most commonly occurring disorders. But for 15 years Services have travelled the ‘Complexity’ pathway, with no discernible added value. Unfortunately it does not appear that this bandwagon will stop anytime soon. Perhaps the tide will only turn when people question the economic case for ‘Complexity’?

    Dr Mike Scott

  • Currently, Psychological Wellbeing Practitioners (PWPs) are expected to attend workshops sponsored by the developers of computer assisted CBT (Silver Cloud) and an artificial intelligence company (Limbic). But what will this achieve for the person in the street? At present 1 in 3 people attend just 1 assessment/treatment session in NHS Talking Therapies [Scott (2024)]. Are they seriously more likely to engage more with a computer/AI? The obvious need is for a therapist to give the distressed person the time of day to tell their story and respond appropriately. Reading from a script is insulting. There is no independent evidence for the Service’s claimed 50% recovery rate, the likely true figure, Scott (2018), is a tip of the iceberg recovery rate. To raise these concerns in one of these workshops or indeed in the Service itself, will likely evoke the following response:

    The sales pitch for Workshops is to:

    • boost productivity using AI tools chatbots and digital solutions
    • tailor therapy for neurodivergence with practical, trauma-informed approaches
    • adapt to new key performance indicators
    • determine suitability for low intensity CBT
    • consider that all-comers should get low intensity CBT first.
    • determine unsuitable referrals
    • manage complexity

    PWPs have, in necessary pursuit of CPD, entered a ‘brave new world’. But this is pure marketing, there is no evidence-base that these aspirations can be delivered in the real-world. Rather the PWPs are likely to continue to function in a parallel universe to that inhabited by most clients. Whilst attendees are encouraged to learn from each others ‘best practices’, dissent from NHS Talking Therapies modus operandi is unlikely to be tolerated, the ‘thought police’ will be in operation.

    Overall there is as I said in a recent post a ‘I’m sorry, I don’t have a clue’ response from the gatekeepers to psychological treatment. There is a pressing need to review fundamental methodology.

    Dr Mike Scott

  • Not a Radio gameshow, but NHS Talking Therapies practitioner’s felt responses to encountering clients who mention trauma,  revealed in a paper by Kerr et al (2025) in the The Cognitive Behaviour Therapist. Psychological Wellbeing Practitioners (PWPs) are the gatekeepers into the Service,  but in  this study they report being out of their depth, unable to differentiate trauma responses. With no training in reliable diagnosis or trauma treatment. But clients are unaware of this. Whither transparency?

    The authors of the paper are Oxford University researcher’s, they studiously avoid saying that the assessment process in NHS Talking Therapies is fundamentally flawed. To do so may scupper their access to data from the Service and embarrassingly, underline that the assessment process employed, originated with one of their colleagues.

    I assessed John (some details changed to protect confidentiality) who fell from a ladder, and was unable to work as a painter and decorator for many months. He developed depression and panic disorder. John was routed via his GP to NHS Talking Therapies, where he had 7 sessions of ‘low intensity CBT’. He was deemed by the PWP to have ‘PTSD/like symptoms’ and put on a waiting list for ‘high intensity CBT’ , where he is currently languishing. John hadn’t been informed that he would likely have trauma-focussed CBT involving repeated reliving of his fall! There was no precision in the PWP’s assessment. The fall was undoubtedly a stressor, but it was very unlikely that it was the extreme stressor required for a diagnosis of PTSD. I conducted a standardised diagnostic interview for PTSD, enquiring about each symptom and whether each cleared a threshold for significant impairment. He quite definitely did not have PTSD.

    But most people have experienced a trauma in their life, and those who go to NHS Talking Therapies will be no exception. If the gatekeepers, the PWPs, are at sea on this, the whole service is questionable.

    Dr Mike Scott

  • That is the prediction of Alan Frances in a just published British Journal of Psychiatry paper. He is a leading US psychiatrist and a major figure in the development of the DSM criteria. Yet just returning from the European Conference on CBT at the University of Glasgow, I did not come across any mention of AI. There were attendees from over 60 countries and over 2000 CBT afficionados. But there is clearly a major issue to address in terms of clients and psychological therapists. Bluntly, jobs, could be on the line.

    Alan Frances notes that psychotherapy and guidance on managing everyday difficulties is the most common use of AI. Frances believes that AI is just as good as traditional treatments for mild anxiety and depression. He suggests that an advantage of AI is that it makes engagement of clients easier, in that it is available 24/7 and that there is no shame in disclosing highly personal information to a machine. Frances notes massive investment in the development of AI for mental health problems with an associated likelihood of massive marketing. In this context empirical investigation of outcomes is likely to be given scant attention. Governments and service providers are likely to be carried away by the anticipated huge savings in staffing costs, ignoring misgivings about effectiveness. Frances argues most clients will gradually opt for the accessability, convenience and reduced costs of artificial intelligence. Artificial intelligence chatbots place a premium on pleasing the user, as this is the most likely to be financially lucrative, rather than being governed by what is clinically important. The developers of AI therapy have little accountability.

    But the evidence base for the effectiveness of AI in treating mental health problems is weak. Frances’s contention that AI is as good for treating mild anxiety and depression as traditional treatments is unproven. Nevertheless, my own research Scott (2018) on NHS Talking Therapies clients, suggest only a tip of the iceberg recovery rate. It would be no surprise to find that AI therapy has comparable efficacy, or more accurately lack of efficacy. But AI may be more engaging. For every 2 people having 2 or more treatment sessions in NHS Talking Therapies 1 has just one assessment/treatment session Scott (2024). To my knowledge AI has no demonstrated efficacy for severe mental illness. It could be argued however that in this context it is no different to traditional treatments. 

    In essence AI is like a photocopy of ‘good practice’. But the presumption is that the ‘good practice’ has first been rigorously evaluated. Importantly that the supplied data was ‘falsifiable’. If data from routine psychological therapy was used as the database, with Service providers stipulating what is ‘good practice’, then no steps have been taken to ensure that it was possible to prove that the service was ineffective. In such instances any observed improvement could be due to time, attention and a credible rationale. Thereby making AI a worthless photocopy. In computer terminology It is a matter of GIGO, ‘garbage in and garbage out’. Routine psychological treatment will be, sooner or later in the ‘dock’, whilst there are no signs of it being able to make a ‘robust’ defence, my guess is that the ‘judge’ [political masters, Department of Health] will be swayed by the plausibility of the case presented and the new-found ease of providing services. The acoustics will prevent listening to the voices of clients. There needs to be a ‘wake-up’ call to examine these issues.

    Dr Mike Scott

  • Just looked at the conference program that I will be attending, remotely, later this week. What struck me is that the overwhelming majority of presenters are University-based, with a few non-university-based presenters, running skills classes. But I guess only the tip-of-the iceberg of attendees will be University-based. I am sure that this isn’t a deliberate ploy on the part of Conference Organisers, But it is an issue that has not been recognised since the inception of BABCP, much less addressed.

    Lived experience seems not much in evidence. The danger is that suggested interventions will be eminence-based rather than evidence-based. With University staff often charismatic. The only protection for most attendees is to use the mnemonic PICOT, in gauging the relevance of what is presented.

    Asking the basic question ‘what proportion of people with the said difficulty/disorder, are back to their old selves following this intervention and for how long?’ Presenters may well fudge their response.

    Oftentimes I have found I’ve picked up something really useful at a Conference by attending something that is off my ‘beaten track’. Hopefully this will happen again.

    Years ago there was the CBT Cafe as a CBT discussion group, but this fell into dis-use – I think because of the pre-eminence of some contributors. I was disappointed that it has not been resurrected in some form on the new BABCP website. But I can see that the task of moderation is onerous, nevertheless there is danger for any Organisation if there is not open discussion.

    Dr Mike Scott