Michael J Scott

  • Why then is the Health Secretary, Mr Sweeting – wasting £2bn a year on NHS Talking Therapies.?

    The professional groups providing psychological services are a powerful lobby. It was announced on the June 25th, 2025 that BABCP (British Association for Behavioural and Cognitive Psychotherapy) and the British Psychological Society (BPS) would welcome into their fold:

    • Mental health well-being practitioners.
    • Psychological well-being practitioners.
    • Education Mental health practitioners.
    • Children’s well-being practitioners.

    The president of BABCP , Dr Stirling Moorey said that this is a. “Significant step forward in quality assurance, public protection and professional recognition’.

    But in what way will ‘quality assurance be increased?’. Better than AI? The AI advocates have used the same flawed methodology as NHS Talking Therapies, neither have looked at the proportion of clients who have returned to their old selves post-treatment for what they sees as a meaningful period as assessed by independent assessors. There has been no real listening to clients.

    An AI Chatbot (Therabot) appears to do just as well as NHS Talking Therapies for clinically significant symptoms of depression and GAD [Heinz et al (2025)]. The study used the same outcome metric, changes on psychometric tests.  Results were compared with a waiting list control. The Therabot intervention lasted 4 weeks, and there was a 4 week follow up. Average use of the intervention was greater than 6 hours. The authors claim that participants rated the therapeutic alliance as comparable to that of human therapists. For depression an 8-point change in score by the follow up, compared to a 4-point change for those on waiting list. For GAD a change of 3.2 compared to a change of 1.1 for those on the waiting list. 

    Psychological Wellbeing Practitioners (PWPs) arrived on the scene 15 years ago as part of the IAPT Service , welcomed by BABCP/BPS. However there has been no evidence of an added-value of their ministrations over and above what was on offer before. Whilst it is the case that there has been increased access to ‘psychological interventions’ there has been no evidence of this making a real-world difference to clients lives beyond that which obtained pre IAPT . Most parsimoniously the new designations looks like an exercise in empire building, gifted by NHS England.

    The Government is set to abolish NHS England within 2 years. It seems that this body and its’ products are not fit for purpose.  Mr Sweeting has vowed to make a bonfire of quango’s but hasn’t yet lit the blue touch paper, the AI study may encourage this.

    Yet doubtless BABCP/BPS will struggle strenuously to ensure that £2bn a year continues to be spent on these service. Mr Streeting, Health Secretary , should ask why?

    Last year the Spanish Society for Clinical Psychology published my paper ‘The UK NHS Talking Therapies Fantasy’ it should be on the required reading list of the Health Secretary.

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    Dr Mike Scott

  • In March 2025 the government announced the end of NHS England within 2 years, with a move of staff and function to the Department of Health and Social Care. Integrated Care Boards, who oversee much of mental health provision, are being asked to achieve a 50% reduction in costs. Jobs are likely on the line. The pressure will be to avoid any ‘talking’ in favour of digital ‘solutions’ such as Silver Cloud. A recent exchange on Twitter highlights the extreme dissatisfaction with NHS Talking Therapies attempt to do things on the cheap! The paradox will be ‘talking therapies, don’t talk’.

    Psychological treatment is following an ‘entropy trajectory’, where energy becomes progressively available in a less useful form. The process starts off reasonably well, with randomised controlled trials showing CBT treatments are better than active control conditions, but a paucity of evidence on how long gains last. Further it is not clear what this means in the real-world.I have found it impossible to discover what proportion of those given CBT would say that they recovered in the sense of being back to their normal selves for what they would see as a meaningful period. When the rcts have been evaluated in routine practice , there has usually not been independent assessment. Thus whilst a case can be made that ‘efficacy’ is proven, not so for ‘effectiveness studies’. When it comes to routine practice the energy is further degraded, it is only the Service providers who claim a 50% recovery rate. My own independent analysis as an Expert Witness to the Court suggests a tip-of-the iceberg rate of recovery. Most likely explained by giving people simply time and attention rather than anything to do with CBT.

    Unfortunately, Service providers and lead organisations for CBT are likely to push as far as possible f or the retention of the status quo. But in w hose interest?

    Dr Mike Scott

    • The dropout rate from trauma focused treatments (TFTs), in randomised controlled trials is 1 in 4
    • With a 50% recovery rate, but in routine practice only the tip-of-the iceberg recover
    • TFTs are not user-friendly for clinicians or clients, as the latter rarely want to re-live their trauma
    • But there is a new way forward – gradually daring the client to think and behave as they did pre-trauma. At the same time challenging the relevance of the intrusive memories to what they might do today. That is, changing the window through which they view themselves and their personal world.

    The Powerpoint presentation below highlights this different pathway:

    https://www.dropbox.com/scl/fi/zh3owqemrdh4vcac7j14o/Reconceptualising-Trauma-Treatment-2025.pdf?rlkey=0rwfvr5djghnag5tt8n5zu49m&st=qk09aany&dl=0

    Scott, M.J (2022) Personalising Trauma Treatment: Reframing and Reimagining London: Routledge and

    Scott,M.J (2024) Moving On After Trauma 2nd Edition London: Rutledge

    Dr Mike Scott

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      Across countries, Attention Deficit Hyperactivity Disorder (ADHD) and Autistic Spectrum Disorder (ASD) have become the ‘go to’ explanations for:

      • difficult or unusual child behaviour
      • an unresponsive partner
      • a difficult employee or manager
      • long term dysfunctions

      Before the millennium very different explanations would have been proferred. Are there really more casualties? Are we now any better at resolving these issues?

      Difficult to assess true prevalence because there are no biological markers for ADHD/ASD. This comes as a surprise to most users of the terms. It should generate caution when a child is placed on a ‘pathway’ for one and sometimes both of these disorders. Or when a person re-interprets what they see as long-term dysfunction in terms of one or other of these labels. Due consideration should be given to alternative simpler explanations and treatments. But mental hypochondria rules, the equivalent of seeing a headache as signs of a brain tumour, which would evoke a ‘not impossible but really….’ response.

      Propelled by pharmaceutical companies and designated specialist Units, the ADHD/ASD juggernaut has acquired such momentum that it may be regarded as ‘churlish’ and ‘unprofessional’ to question it. Defenders of these constructs, can rightly point out that there are no biological markers for any of the psychological disorders. But this does not seem a sound basis for multiplying diagnoses. Curiously these disorders do not figure in the NHS Talking Therapies lexicon, nor where they a focus in the most recent meta-analysis of the efficacy of CBT treatments Cuijpers et al (2025). In subsequent posts I will look at the validity, utility and authority behind the supposed treatments of ADHD/ASD.

      Dr Mike Scott

    • Seeing the brain as a computer, has great value in teaching students how information processing biases, such: ‘as all or nothing thinking’, ‘personalisation’, ‘mental filter’ etc can create distress [See Scott (2016)]. However, metaphors can be pushed too far.

      Probably the most glaring example of this, is in the use of ‘arrested information’ to explain ongoing debility post-trauma. Arrested information processing is an article of faith in CBT orthodoxy and EMDR necessitating, it is believed, trauma-focused treatment (TFT). Consequently when TFT doesn’t work there is dismay, for clinicians and clients. Unfortunately, TFT not working is commonplace. For veterans ,the recovery rate is 30-40%, and for civilian trauma, on average, about 50% [See Scott (2022)].

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      Understanding ‘arrested information processing’ is quite simple when it comes to a computer. I might fail to print out this post because I have failed to press the ‘print’ button, or I’ve forgotten to put paper in the printer or perhaps the cable from my printer to the my desktop has become loose. But applying this concept to the concerns of a traumatised bomb victim, would strike most people as ‘decidedly odd’. It is possible to socialise people to improbable ideas, if their livelihoods depend on it. But such ideas are still prone to evoke a ‘give us a break’ gut reaction. Which can nevertheless be overridden by peer or organisational demands. In Scott (2022)I have argued that the centrality accorded to the trauma is a more plausible explanation of ongoing debility post-trauma. Further it has user-friendly treatment implications, thereby easing dissemination efforts. Despite this there is no evidence of any paradigm shift, no consideration of the counterfactual, this looks suspiciously like dogmatism.

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      Whilst ‘arrested information processing’ is one of the by-products of identifying the brain as a computer, there are further ‘harms’. The implication is that if the individual could rid themselves of such ‘biases’ they would be happy. But such biases are also the property of those without a psychological disorder [See Daniel Kahneman’s work]. It is difficult to escape thinking that the therapeutic goal is t o create the ‘rational’ person much esteemed in the Enlightenment. Here we run into philosophical trouble, as no computer can tell a person what they ought to do. The computer might describe what ‘is’ e.g the proportion of children in poverty, but not what ought to be done about it. The ethical judgements are in a different category, to the computers concerns – as are judgements about who to reverence and what would constitute purposive behaviour. Indeed anything that makes us human is outside the orbit of a computer.

      These considerations appear abstract, but a common client presentation is a depressed client with physical injuries. One could embark on the standard activity scheduling and the likelihood of it improving mood. But oftentimes this doesn’t get off the ground. Here the purposive dimension could be important, if historically he/she had always thought it important to ‘give people the time of day’ this could be re-ignited to fuel the standard CBT therapy, this is going outside the rational but is not irrational, just human. CBT may be the rocket but purpose is the blue touch paper.

      Dr Mike Scott

    • Supervision is a necessary part of professional registration, often much valued by practitioners. Service providers insist on it. But there is a dearth of evidence that supervision per se affects client outcome, Watkins et al (2019). It may be that CBT supervision , will outperform the myriad forms of supervision examined by Watkins et al (2019), but there is no evidence of this. As such evidence-based CBT supervision is a myth.

      In supervision there is a relational continuity often missing from low intensity CBT interventions. What supervisees typically bring to supervision are cases that may seem beyond their resources – mini-crises. The supervisor likely proffers help to ‘put out the fire’. But it also goes beyond ‘fire fighting’ to alert the supervisee to an appropriate evidence-based treatment and discuss the personalising that may be needed for the supervisee’s client. This was the type of supervision that I advocated in Simply Effective CBT Supervision, Scott (2013). But there is no evidence of its’ adoption in routine psychological treatment.

      Service providers use Supervision to help achieve operational goals, reduce waiting times and ostensibly achieve a 50% recovery rate. But without independent evidence of the achievement of such a recovery rate. Rather it is a key performance indicator with which to terrorise clinicians, using the Service providers own idiosyncratic metric. Little wonder burnout is extensive!

      Dr Mike Scott

    • This is the title of the seminal 2nd Edition of this work, by David F Tolin, published last year by Guilford Press. He sees CBT at its’ core, as focussed on the reciprocal interactions of cognitions, behaviour, emotion and physiology. So that changing any one will impact on the others. This will be very familiar to all CBT therapists, for example if feeling low you could go for a walk (physiology) or alternatively change your thinking from ‘I have too much to do’, to ‘ I can get through it all, if I just pace myself with breaks, doing only one task at a time’. The strategies adopted synchronise with each other. Interestingly he describes his way of doing CBT, which he acknowledges might not be how another expert clinician might conduct CBT. This could be regarded as flexibility but it also may cause problems with regards to fidelity.

      For example he advocates, p xi, ‘that we de-emphasise the DSM In favor of a broad set of principles …which we can apply to all our clients, no matter who they are or what problem (s) they have’. But Judith Beck in CBT The Basics and Beyond (2020) states that the first thing she does is a diagnostic evaluation. Throughout her book she describes the treatment of 2 clients one with simply depression and the second with depression and a borderline personality disorder.

      Without categorisation both clients would likely have been treated in the same way.

      Tolin makes no mention of cognitive content specificity i.e that disorders are distinguished by their different cognitive content. Knowing the disorder(s) likely flags up a particular set of cognitions to be addressed, for example in PTSD those embodied in the Trauma Cognitions Inventory, Scott (2024) Moving On After Trauma 2nd edition. Without this the nascent CBT therapist might ‘zap’ every negative cognition in sight.

      Fidelity is more difficult to gauge with Tolin’s approach. He states that clients can be advised of a 50% recovery rate across the anxiety disorders on the basis of randomised controlled trials. Though on average treatment gains were maintained, it is unclear from the rcts what proportion of clients maintained recovery for say 6 months. This is the real-world data of interest to clients.

      Clinicians working in routine practice have to be accountable, but this cannot be easily demonstrated if a therapist is doing their own version of CBT. Treatment integrity is a major pressing and unaddressed issue in routine practice. Service providers have shown no inclination to address this, perhaps fearing that to do so might threaten their very existence. Neither Beck or Tolin, address the very different working context of routine practice, where I suspect flexibility has become infidelity.

      Dr Mike Scott

    • There has been a burgeoning in the growth of psychological treatments in the UK. But with no evidence of a decrease in the prevalence of psychological disorders. As such the case for this expansion looks weak. This has been termed the ‘treatment-prevalence paradox’.Ormel et al (2022) https://doi.org/10.1016/j.cpr.2021.102111]

      The paradox’ should cause a pause for stocktaking, but none is in sight. There are vested interests in the 65% increase in psychological therapists between 2019 and 2024. With ever more expansion planned. The justification looks as weak as the case for international expansion of borders.

      Ormel et al (2022) suggest there is a problem in generalising from randomised controlled trials to the ‘real-world’ casting doubt on NHS Talking Therapies assertion of equivalence of outcome. The latter are generating over-optimistic predictions of outcome, welcomed by politicians, media, funding bodies and service providers but demoralising for clients. It seems a fitting subject for the TV programme ‘Con or Cure’.

      Dr Mike Scott

    • On March 6th, 2025. Ms Liz Kendall. Secretary of State for Work and Pensions said “I think the only way that you can get the welfare bill on a more sustainable footing is to get people into work”. But this is likely to evoke a sense of foreboding amongst the disabled, often scarred by their encounters with the Department of Works and Pensions. The overwhelming majority of those on benefits would dearly love to be in work. It offers the possibility of achievement, social connection and financial freedom. From a governmental perspective, facilitating employment makes perfect sense at every level. But the way to hell is paved with good intentions.

      Employers have for many years operated a phased return to work for those who have been off sick. There is an acknowledgement by employers to make ‘reasonable adjustments’ in the workplace for those with disability. Not to do so risks being taken to an Employment Tribunal (ET). But the consequences of an ET for a large employer are minimal.

      Untrained staff are being drafted into Secondary Care to encourage those with severe and enduring mental illness into work. But as one such ‘conscript’ said to me “I feel I am an ‘imposter’, the clients are lovely, I am told to make a fit between the person and the job’ . Striving to meet key performance indicators she finds daunting, sounds like a recipe for burnout.

      Many of those with mental health disabilities are outside primary and secondary provision. Some have been discharged from secondary care because they are deemed no longer at risk, some that have been refractory to NHS Talking Therapies are deemed not to meet the criteria for secondary care. Professionals have not had the skills to facilitate work engagement. If this enterprise is to work it requires treatments that tackle people’s psychological disorders, in such a way that they have at most mild symptoms of disorder. This doesn’t look like happening any time soon.

      Mike

    • In 30 years of reviewing treatment notes I can’t recall seeing a written homework assignment. But these were an integral part of the randomised controlled trials of CBT for depression and the anxiety disorders. Completion of homework has been found to effect outcome see Kazantis et al (2007) Using Homework Assignments in CBT Guilford Press.

      According to the NHS workforce report there was a 65% increase in psychological therapists between 2019 and 2024.This expansion has come about despite any plausible evidence that CBT is delivered in routine practice. Looks suspiciously like jobs for the boys! What proportion of the 24,000 members of the British Association of Cognitive and Behavioural Therapies (BABCP) would testify to routinely giving clients written homework assignments?

      It is worth recapping some of the benefits of a written homework assignment. It is a succinct summary of learning points from the treatment session, it ensures translation from the therapy room to the real-world, it provides continuity between sessions (sessions begin with a review of the set homework), it provides a personalising of therapy. In the absence of a written homework claims of fidelity to a NICE evidence-based treatment do not stand up in ‘court’.

      Good to be back

      Mike