Michael J 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