Michael J 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

  • 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