Michael J Scott

  • ‘Therapist responsiveness and tailoring treatment to themselves’. These are the main findings from a qualitative study of 148 NHS clients, who had psychological  therapy,  just published by Li et al (2025).

    Therapist responsiveness means actively listening to the client’s concerns and responding to them. In terms of the social psychology ‘Elaboration Likelihood Model of Persuasion‘, the concerns of the client can be peripherally processed, by the therapist, with effortful processing reserved for a specific identified protocol for a disorder.  In the words of the title of this paper ‘It felt like I was being tailored to the treatment rather than the treatment being tailored to me’. 

    A common scenario is a single Mum living in appalling housing conditions. Her children’s asthma worsened by the mould. The Social landlord has repeatedly failed to address matters. She is severely depressed and the therapist is preoccupied with a Behavioural Activation (BA) programme. Notwithstanding, that she is too embarrassed to invite family/friends to her home.

    Effortful processing on the part of the therapist would have been discussing possible legal action against the Landlord.

    But the job of triaging clients in NHS Talking Therapies, in practice, usually falls to   Psychological Wellbeing Practitioners or a social science graduate, neither of whom are trained therapists.  They do not have the competence to deal with the psychological and social.  The ‘PWPs’ are under pressure, with typically just 6 treatment sessions at their disposal. They may see this single Mum as unsuitable for the service or plough on with a short course of BA. However, the Mum is likely to attend only one assessment/treatment session. With regards to depression for every one person attending one session, two people go on to have 2 or more sessions [Scott (2024)]. There is an unrecognised, massive haemorrhaging of clients at triage. Comparable in scale to booked appointments for an assessment/treatment session that is not attended. 

    There is however a fundamental flaw in the Li et al (2025) paper,  they state that the Improving Access to Psychological Therapies Programme (the predecessor of NHS Talking Therapies) has been ‘internationally recognised for its effectiveness in psychological care on a large scale’, citing David Clark the prime mover in the development of IAPT and Wakefield et al (2021). Neither of these sources can claim independence of the Service, the corresponding author in the Wakefield et al study was an IAPT programme director. I wrote a rejoinder to the Wakefield et al study in the British Journal of Clinical Psychology,  in which my own analysis of 90 IAPT cases as Expert Witness to the Court, showed that only the tip of the iceberg recovered [Scott (2018)].

    Dr Mike Scott

  • Group treatments are a response to long waiting lists for individual therapy. They can also help to normalise a child’s difficulty and help parents to feel less isolated. In recent years there has been a trend away from diagnosis specific groups to transdiagnostic groups. But a just published paper in the Clinical Psychology Review of 80 studies suggests they are no more effective than active controls. Rather than answer whether ‘going transdiagnostic’ represents added value over traditional disorder specific interventions, (the appropriate counterfactual), these authors simply make a case for more rigorous research.! In this vacuum marketing is likely to win – 29 of the studies were by author’s of the developed protocols.

    Caution is needed in translating these studies to routine practice:.

    • Only 1 of the 80 studies was conducted in the Uk, a mentalisation based treatment for youth.
    • Half the studies had parental involvement an average of 8 sessions. The children had on average 11 sessions.
    • 59 of the studies were of CBT consisting of mindfulness, emotional regulation and cognitive restructuring. But the author’s of the studies, self-labelled their interventions. The meaning of ’emotional regulation’ was unclear.
    • 14 of the studies involved children with ASD or ADHD.There is a bottleneck in the UK for ASD and ADHD assessments, as they are the passport to extra help at school. In this context Group Transdiagnostic approaches are likely to be heralded as, at least a ‘first-line approach’. Welcomed by schools to head-off the extra staffing investment this ‘passport’ would confer. Parents may be led to believe that their children are getting a new evidence-based treatment. Service providers are likely to seize upon transdiagnostic group interventions as a simple solution to the pressure of referrals. There is a need to look beyond convenience. 

    In ‘Simply Effective Group CBT’ London: Routledge (2011) I detailed how it was perfectly possible to address the commonplace additional disorders in this modality with Adults, without losing focus on the principal disorder. But over the last decade the conventional wisdom has been to label the additional disorders as constituting ‘complexity’, with a supposed need for a ‘complex’ intervention. However there is no empirical evidence that this shift in focus has resulted in better group CBT for adults. Unfortunately the ‘complexity’ myth has spread to interventions with the young.

    Dr Mike Scott

  • According to a recent British Journal of Psychiatry editorial, the absence of biomarkers for any psychiatric disorder has been used to call into doubt, the whole diagnostic enterprise in mental health. But the editorial suggests that the absence of biomarkers in general medicine is commonplace. Whilst a biomarker can indicate a mechanism of dysfunction, it cannot determine whether pathology exists. The determination of pathology cannot be outsourced to biology.

    The assessor is an actor in the determination of pathology and a conduit for societal values. It appears that in the very act of trying to gauge pathology, what is the focus is being changed. The situation seems akin to in physics, that the more that one determines the position of an atomic particle the more uncertainty there is as to its’ velocity and vice versa (the Heisenberg Uncertainty Principle). It appears that for the foreseeable future, it’s likely to be a matter of clinicians muddling along with diagnostic categories, that may not be carved into nature, in the absence of a better way of categorising difficulties and corresponding treatment options. A great deal of humility is called for, not the strong suit of many psychiatrists or psychologists. 

    NHS Talking Therapies operates a free for all, its’ clinicians ascribe a diagnosis based on ‘ICD-codes’ and not on any standardised diagnostic interview. Making for highly questionable reliability. Nonetheless luminaries of ‘critical psychology’ have used NHS Talking Therapies data to substantiate the very significant withdrawal effects from antidepressants.Whilst I don’t doubt that this is a very real issue, they don’t at all raise the issue of the reliability of NHS Talking Therapies data. One is reminded of certain President’s inability to criticise other Presidents.

    Dr Mike Scott

  • I-Phone now provide the facility for users to complete the PHQ-9 and GAD-7 and get feedback on the results https://support.apple.com/en-gb/guide/iphone/ipha8d27408f/ios. They caution that the results only indicate the ‘risk’ of developing anxiety (measured by GAD-7 score if over 13) and depression (measured by PHQ-9 score if over 18). But they provide no quantification of the ‘risk’. The I-phone suggests that those with PHQ-9 scores of 10 or more or GAD-7 scores of 8 or more should consult their GP/Specialist. If only a small proportion of the 1.5 billion I-phone users did this, it would likely overwhelm front-line services, crowding out those who do really need a clinician’s help.

    Most people appreciate that every drug has a side effect. But what is not appreciated is that a psychometric test, administered in isolation, has serious adverse consequences – false positives, for every person correctly identified between 1-4 other people are mislabelled and likely mistreated. I explain how this comes about at the. end of this blog. Suffice it to say for now that there is no evidence that scores on these tests, administered without specification of context, predict anything.  Scores can be high for myriad other reasons, than depression or anxiety, e,g exam results, strained relationship, housing disrepair, disorders other than anxiety or depression. For example, a just published study on bulimia in Japan, found a quarter were suffering from depression. The public are likely to dismiss the smallprint about ‘risk’ because of a lack of understanding, unwittingly creating a ‘mental hypochondria’. But don’t worry, before long Apple will develop an App for measuring this construct, despite it lacking any validity. The results can then be easily integrated into AI generated therapy. It is no wonder that Illinois has already banned AI Therapy. 

    Tests are very good on sensitivity, i.e they identify the vast majority ( about 90%) of people who have a disorder. The downside is that they have poor specificity (about 60%),correctly identifying barely half of those who do no t have the disorder. Imagine a 100 people are assessed with a ‘gold-standard’ diagnostic interview, it will likely identify 10 of them as being depressed (top left hand column below) and 90 as not having depression (top right hand column below).Those who do not have a disorder are far more numerous those who have a disorder. Applying the test to column one, 9 out of 10 would be above the cut-off and 1 below. Moving now to the 2nd column, the 90 people who do not have the disorder, the test only gets 60% of these right, ie 54 people, and gets 36 people wrong. Thus there are 9 people that the test got right versus 36 people that it got wrong, thus for every person it got right, it got 4 wrong.

    Imaginary Sample of 100 clients

    Depressed n=10Not depressed n=90
    Above the cut-off n=9Above the cut-off n=36
    Below the cut-off n=1Below the cut-off n=54

    The adverse consequences of the test are that approximately 4 times as many people are screened positive as have the disorder. Thus by itself the test would lead to rampant invasive treatment. Using the analogy of breast screening many more tests would be conducted before surgery or chemotherapy. However with the sole test used in NHS Talking Therapies there are no such checks and balances.

    When the PHQ-9 and GAD-7 have been evaluated alongside a diagnostic interview, the tests give a prevalence rate two to three times higher. Patients with principal diagnoses of post-traumatic stress disorder, obsessive compulsive disorder, specific phobias and adjustment disorders commonly score above thresholds on these tests. So that when these tests are reified the test completer Is nudged in the wrong treatment direction,.

    Completing these tests fits neatly into the time slot of the typical GP consultation time of 10-15 minutes. Psychological therapists will likely not see the use of the I-phone in the therapeutic hour as too burdensome, conferring a ‘scientific glow’ to proceedings, even if they do not know what they are measuring. 

    Using the PHQ-9 the natural recovery rate for depression amongst GP patients administered an antidepressant was 47% within 3 months [Moore et al (2012)]. So that ‘watchful waiting’ is probably best in the 1st instance , waiting for the Storm to pass rather than heading into the eye.

    Dr Mike Scott

  • Pseudo-diagnosis is rampant. Psychological therapists in NHS Talking Therapies are expected to generate a diagnosis for each client. But the Service states[Manual 2024)] that its’ diagnostic labels should not be used for medico-legal purposes! If they are not reliable enough for the Courts, how can they be reliable enough to guide treatment decisions? Confusingly, the Service states that its’ clinicians are not trained to diagnose.

    I have signed up to attend the BABCP annual jamboree in Scotland this September. I can confidently predict that the outcomes of much vaunted treatments will not be based on pre and post ‘gold-standard’ diagnostic assessments. Much less will they be based on independent blind assessment. Enthusiasm for interventions will greatly outstrip evidence. For whose benefit is the evangelical fervour for CBT?

    • those seeking employment as CBT practitioners
    • providers of NHS Talking Therapies Services
    • beleaguered NHS staff
    • politicians concerned to ‘prove’ ‘that at least they get some things right’
    • integrated Care Boards

    No one in their right mind is going to publicly dissent. The likelihood is that the deafening silence of the past 17 years will continue. “Repeat a lie often enough and it becomes the truth”, is a law of propaganda often attributed to the Nazi Joseph Goebbels.

    As with all propaganda, the losers are the person in the street. This is not to say that people cannot benefit from CBT but that they do not do so routinely [Scott (2018)].

    Dr Mike Scott

  • At a cost of £2 billion a year for adult and child mental health services. NHSE manages NHS Talking Therapies without any acknowledgment of a failure of governance. It is or should be aware that pychometric tests results provide, at best, circumstantial evidence of effectiveness.

    But it presses ahead with its conviction of a 50% recovery rate. It is akin to a person being convicted of an offence on the surmise of a policeman. The failure of NHS England and Talking Therapies has been going on as long as the Post-Office scandal, but with a determined blindness on the part of power-holders.

    Blood pressure monitors are a useful device, good for charting hypertension, but unlikely to be relevant to your knee pain. In a similar way, the two psychometric tests, beloved of NHS Talking Therapies, the PHQ-9 and GAD-7, are relevant only if the person is known to be suffering from reliably diagnosed depression or generalised anxiety disorder. No reliable standardised diagnostic interview is conducted in NHS Talking Therapies, in this context the questionaires are meaningless.  In NHS Talking Therapies clients complete these measures at the beginning when they are likely at their worst. With the passage of time, as crises subside, and with attention, scores improve. But test scores improve just as well when clients attend the Citizen’s Advice Bureaux. There is no independent evidence of recovery from any of the psychological disorders that are supposed to be the focus of NHS Talking Therapies.

    The reports of NHS Talking Therapies clinicians invariably quote PHQ9 and GAD7 scores and the improvement in them as evidence of effectiveness. As an Expert Witness to the Court for over 30 years, I have to regularly point out that the clinician’s reports cannot be relied upon. In a backhanded admission of the unreliability of clinicians reports, NHS Talking Therapies states that their reports cannot be relied upon for medico-legal purposes! Between NHS England and NHS Talking therapies there is a con going on here. The clinician is like a footsoldier in a totalitarian state, doing what he/she is told. The public are failed. The questionnaires are fake news. Perhaps the good news is that NHSE will be abolished in he next 2 years, but will the Department of Health and Social Care want to grasp the nettle?

    Dr Mike Scott

  • Nobody is asked whether they are back to their old self with treatments or of the duration of recovery. But these are the metrics that are most important to service users. It appears that evaluations primarily meet the needs of service providers and their academic fellow travellers. The NHS controls Service Providers and it is in their interest to use self-report measures, that give a positive spin to their ministrations. People present at their worst and so there is an inevitable seeming improvement with attention and time on a questionnaire. It is spin not to present apparently positive results in the context of what happens to those not given treatment. The reality is Talking Therapies clients does no better for clients than if they had attended a Citizen’s Advice Bureaux.

    In routine practice service users are asked to complete a psychometric test, when their score falls below a cut-off they are discharged. But there is nothing in the process to guarantee:

    1. the test that was administered is appropriate to their diagnostic status 
    2. the score achieved is a surrogate for loss of diagnostic status as assessed by a blind independent rater using a standardised diagnostic interview
    3. that there has been an enduring change in the service users functioning that they would recognise

    But the same considerations apply to the assessment of the impact of antidepressants. A blog from John Read, Professor of Clinical Psychology at the University of East London shows that the focus has been on the impact of medication over 8-12 weeks and the experience of withdrawal symptoms such as nausea, dizziness as assessed on a scale. Notwithstanding that most patients have been on antidepressants for years and that the withdrawal symptoms are the least of their concerns, ‘I’m still bloody depressed’. 

    Dr Mike Scott

  • In Personalising Trauma Treatment: Reframing and Reimagining Scott (2022), I suggested that we can retrieve memories of extreme trauma, in our ‘Dr Who, Tardis’, and that  this may lead to the persistence of PTSD. But we also retrieve, lesser traumas such as bullying at work or being publicly-shamed, that result in ongoing debility. I argued that it is the centrality accorded to these experiences that produces dysfunction rather than the negative event per se. Such experiences may become the window through which the individual views themselves and their personal world. Treatment involves consideration of viewing the self and personal world through other windows, including the pre- trauma window.

    A just published study by Kredlow et al (2025), has found that negative autobiographical memories are also related to patient symptoms in the anxiety disorders and OCD. Nonresponse rates in CBT are estimated to be 34-50%. Thus, targeting negative life events that are related to an individual’s symptoms may improve treatment outcomes. Patients could be asked whether there are any key memories from their lifetime that they believe have contributed to their fears ( SNAMs, Symptom Relevant Negative Autobiographical Memories).The SNAM Event itself may not be as clinically relevant as to how an individual remembers and interacts with the SNAM.

    Formulations can be enhanced by an awareness of mental time travel. Examining in session how homework compliance may have been coloured, by ‘Tardis excursions’ since the last session.

    Dr Mike Scott

  • It was distressing this week to hear, at the opening of the Inquiry, of the ongoing traumatisation of children, which included reports of:

    • A child hiding under a table not wanting to go to school
    • A child constantly looking over their shoulder when outside
    • A child very frightened by loud noises or sudden movements
    •  The alarm of a parent that there was no adult around to assist their child

    About the same time as the murders, the 2nd edition of my self-help book ‘Moving On After Trauma’ was published by Routledge. In it I suggested that there is no need for victims to relive the trauma, rather to gradually behave as they did before the trauma. These can be seen as ‘dares’, and to most children are what makes life fun. It is ‘daring’ to get back to your old self. For both children and adults, it’s not possible to be your ‘old self’ without beginning to do what you did before the trauma. 

    The good news is that there can be ‘normal service’, but for many it feels ‘spoilt’ by the flashbacks and nightmares. The best that can be done is to insist that these intrusions don’t have the last word. Just blocking the memories, gives at most temporary relieve, the harder the memories are pushed away the stronger they return, as if on an elastic band. But the intrusions gradually lose their power if the person can say they are not relevant to what I’m doing today. The only purpose of the intrusions is to daily ask whether the memory is relevant to today, it is only the mind asking a question for possible protection. The vividness of the memories does not make them relevant. For a child they can be seen as a ‘bully’ who they are not going to get involved with ‘better things to do’. Or as a ‘sore’ that they mustn’t pick at, lest the inflammation becomes worse than the sore. 

    Parental guilt can get out of control when harm comes to your child, ‘my job is to protect them’. It can lodge in your gut even though you know you have done nothing wrong. Trying to cut it out seems to make it worse. It is a bogus guilt, unlike true guilt, were you can see the negative consequences of something and do it anyway. This bogus, trauma-related guilt is best dealt with as a ‘mental cold’, ignoring the discomfort as you would a cold when you have to work. Over time the guilt feeling fades but you can’t hurry it along. If you are not careful with this you can develop a ‘prejudice’ against yourself, which like all ‘prejudices’ gets in the way. Don’t become ‘bigoted’ against yourself.

    Hope this helps

    Dr Mike Scott

  • Is usual care worth a monkey? Or more precisely the £2bn per year spent on NHSTalking Therapies for Adult and Children’s mental health?

    Cuijpers et al (2024) anticipated that the response rate of treatment as usual would have improved as a result of the dozens of RCT’s conducted over past decades. Regrettably there has been no percolation. Remission rates and pre- post effect sizes did not significantly improve over time. In primary care the remission rate for care as usual was 27%. The pre-post standardised mean difference in care as usual in primary care was 1.11. But this is no different to that found in NHS Talking Therapies, suggesting that the latter confers no added value. Interestingly the remission rate using independent assessors  in care as usual in the Cuijper et al (2024) analysis was found to be just 14%, Almost 80% of patients in routine care do not respond to treatment.

    This tip of the iceberg response is identical that found by myself Scott (2018) assessing litigants with a standardised diagnostic interview with regards to their psychological treatment either before or after personal injury. (In specialised mental health care the response rate was 20%). In the rcts the response rate to psychological treatment was 41%.

    Dr Mike Scott