The British Association for Behavioural and Cognitive Psychotherapy (BABCP) is the lead organisation for CBT in the UK. It has assiduously promoted the Cognitive Therapy Rating Scale and the PHQ-9, as respectively, the litmus tests of therapist competence and outcome. Students have been failed for performance on the CTRS and clinicians admonished for not demonstrating a 50% recovery rate on the PHQ -9. The two instruments have been pivotal in the giving away of CBT in routine practice for the past 18 years. But they appear to have feet of clay.
The CTRS is only valid if a reliable diagnosis has been made. Clinicians in routine services are not trained to make a diagnosis. Thus a client may present with what looks like social anxiety, but the problem, may be avoidant personality disorder, about which the therapist is clueless. Not only are there treatment competencies, but there are also diagnostic competencies and unless the two dovetail the result is disaster. The situation is analogous to a surgeon being highly competent in knee replacements, performing one, but the problem was the patients hip! see Scott (2014) CBT Supervision. A positive screen for personality disorders predicts a poorer outcome in NHS Talking Therapies, Goddard et al (2015). The CTRS was only validated on a depressed sample, accounting for only 15% of outcome on a clinician assessment. There is no evidence that it is appropriate for use with other disorders. Nevertheless it is commonly used in CBT training for all common mental disorders.
The PHQ-9 is the most widely used measure of the severity of depression. But patients are confused about whether they are being asked about the frequency of their symptoms or how bothersome they find them. Nevertheless it is the metric relied upon by NHS Talking Therapies to declare a 50% recovery rate. With clients admitted or discharged from therapy on the basis of their cut-off score (a case, is a score of 10 or more). Therapists are subjected to criticism if they do not routinely achieve a 50% recovery rate. But the measure only has a 0.48 sensitivity when studies without input by the creators of the instrument a re considered ie, of those with depression it only correctly identifies 1 in 2 of those who have depression Paniyiotou et al 2025. It is not an appropriate measuring instrument if the primary disorder is not depression, but this is routinely ignored.
The routine use of the CTRS and PHQ-9 would struggle to stand up in a Court of law. A student failed because of his allegedly poor CTRS score and bullied over his client’s PHQ-9 scores could mount a credible case. Equally a client could claim that they were subjected to an inadequate, if common treatment, in that it failed to pass any credible test of rationality.
Dr Mike Scott