The Gagging of NHS Talking Therapy Clients

In 2021 Drew et al examined audiotapes of Psychological Wellbeing Practitioners (PWPS)  and revealed that clients were not listened to and the PWPs were hellbent on pursuing orders. Despite this no steps were taken to remedy the problem. Next month there is a webinar on how to shut clients up further, euphemistically termed  ‘Managing Time Boundaries……‘ sponsored by the artificial intelligence company Limbic, the major sponsor of  NHS Talking Therapy events. The advertising reads:

‘Managing Time Boundaries in NHS Talking Therapies
Discover how to have assertive conversations with patients to help build helpful time boundaries and reach their recovery.

This free webinar led by Josh Cable-May, CBT Specialist, Limbic has been designed for NHS Talking Therapies professionals working in IAPT across the country to help you build effective time boundaries. In just one hour, learn how you can:
• Manage the ‘run away’ sessions and regain focus to meet therapeutic goals
• Approach and conduct useful conversations with clients about time boundaries
• Map out clear session objectives and pathways with clients to meet recovery targets’

Thank you to our sponsors Limbic’.
It appears that artificial intelligence is to be preferred to emotional intelligence.

To quote Drew et als’ (2021) study of telephone-guided low intensity IAPT communications:

We show the ways in which the lack of flexibility in adhering to a system-driven structure can displace, defer or disrupt the emergence of the patient’s story, thereby compromising the personalisation and responsiveness of the service’


‘routine assessment measure questionnaires  prioritised interactionally, thereby compromising                        patient-centredness in these sessions’.


Dr Mike Scott


Why Is NHS Talking Therapy The Only Unregulated NHS Service?

With no independent body assessing caring and effectiveness. It has been achieved by IAPT (the former brand name of the service) and BABCP (British Association of of Behavioural and Cognitive Psychotherapies) working under the radar. Their curious tango has prevented the delivery of evidence-based psychological therapy in routine  practice.  They dance for politicians, the Department of Health and Integrated Care Boards (the successors to Clinical Commissioning Groups).

The public face of NHS Talking Therapy and BABCP and their synergy can be seen in an advertised two day BABCP workshop for social anxiety disorder. To be led by Professor David Clark,NHS England’s National Clinical and Informatics Advisor for the Improving Access to Psychological Therapies (IAPT) programme. He and Lord Layard were the prime movers in the development of IAPT.

In advertising the Workshop Professor Clark describes very well an evidence based protocol for treating social anxiety disorder. But there is no evidence any such protocol has has ever been delivered in IAPT. The service has never performed integrity checks for this or any disorder. My own finding Scott (2018) is that only the tip of the iceberg of the Services clients recover in the sense of losing their diagnostic status. NHS Talking Therapies claims to deliver NICE treatment protocols and achieve a 50% recovery rate are self-serving claims, wholly without independent evidence.

The recommended protocol is based on a diagnosis of social anxiety disorder and as the IAPT Manual points out, its clinicians do not make diagnosis and 40% of them are not trained therapists. Both NHS Talking therapy and BABCP have shown no interest in what happens at the coalface, they operate like totalitarian Communist regimes concerned with ideology, operational matters  production quotas, waiting times etc. Like the KGB and Stasi they are superb at working under the radar (see the book Putin’s People) and networking but leaving clients to disappear down a black hole, with almost half of clients not even beginning treatment.

Dr Mike Scott


The Re-Branding of IAPT, ‘Never Mind The Quality Feel The Width’

It is inevitable that when a product fails, it is renamed, so to with The Improving Access to Psychological Therapies (IAPT) service, it is now NHS Talking Therapies, for anxiety and depression.  In 2021 I published a paper ‘Ensuring IAPT Does What It Says On the Tin’ , over the last 2 years it has signally failed to put its’ house in order. On June 28th 2022 the Lets Talk IAPT website identified ‘a series of seven core problems and failings of the IAPT, including an unproven treatment rationale, a weak and contested evidence-base, biases in treatment promotion, exaggeration of recovery claims, under-reporting of drop-out rates, and a significant risk of misdiagnosis and inappropriate treatment’. None of these problems have been addressed and so it has been given an air of respectability as NHS Talking Therapies.

The avowed focus is depression and the anxiety disorders, but it has extended its scope to include the psychological  sequelae of long term physical conditions. Given that almost half the adult population have at least one LTC, this offers massive opportunities for expansion. But the evidence on effectiveness with this population is weak to non-existent.  However given that IAPT has usurped the NHS this is likely to matter little.

Professor Clark and Dr Whittington announcing the name change note ‘”Many of those who do find their way to services are looking for help with other difficulties that the services are not set up to treat, such as psychosis or complex emotional needs associated with a diagnosis of “personality disorder”. Clark and Whittington claim ‘You don’t need a “diagnosis” to come for therapy, a skilled practitioner will help work out with you whether and how the service can help’ and add that they offer treatment not only for depression and the anxiety disorders  but also OCD, PTSD, body dysmorphic disorder, health anxiety and mixed anxiety and depression. But given that its practitioners are not trained to diagnose according to the latest IAPT Manual, by what magic do they decide who to treat with what?   No matter, Clark and Whittington proclaim that 50% of treated people recover, this strains credibility.


Clark and Whittington state ‘Within NHS Talking Therapies services most of the psychological therapy will be quite practical. It may involve working through self-help materials with guidance from a clinician, possibly via a dedicated online platform (which we call ‘digitally enabled therapies’). It may involve help with problem solving skills or practical exercises to examine and overcome your fears. It may involve facing and working through traumatic memories in a safe way’. Can trauma focussed CBT be really regarded as quite practical, in routine practice most clients find it quite toxic Scott and Stradling (1997).


Dr Mike Scott


‘Don’t Worry About Exactly What Is Wrong, Just Throw Everything At It’ 


This is the rule of thumb operated by Service Providers of psychological therapy. Evidence-based assessment has been thrown out of the window. It is buttressed by a belief that diagnostic labels are particularly inappropriate, nay dangerous.  The results are graphically illustrated by this example:

Recently I encountered a 16 year old who had had variously CBT, Dialectical Behaviour Therapy, EMDR and antidepressants over a 3 year period. He put on this trajectory by a clinician who had the impression  that he had generalised anxiety disorder and made mention of some OCD symptoms. But there was no definitive diagnosis. Part way through this period he began to self-harm. At my assessment, conducted with a standardised diagnostic interview, I found that he was self-harming, had generalised anxiety disorder, social anxiety disorder and panic disorder. I searched in vain in the records for any evidence that there had been fidelity to an evidence based protocol for any of these disorders. The nearest I came was discovering from him that he had been invited to distract himself when he had the urge to self-harm. Fortunately the case has not progressed to suicidal behaviour. But it is perfectly possible to imagine such a person might commit suicide. Suppose then the family decided to sue the Service Providers, how would that work out in Court?

How could the Defendant’s convince a jury that they were not a law unto themselves? The Defendants might rightfully claim that their modus operandi was no different to that of other Service providers. Leaving the jury to muse ‘so they are all crap, then?’.

The Judge is likely to be unimpressed by the Defendant’s Expert Witness claiming that the Service providers approach is evidence-based  when no definitive diagnosis has been made, much less the following of a treatment protocol dictated   by the diagnosis.  The Judge acts a a protector of the jury against ‘junk science’, probably even more  so in the United States legal system. She/he will be at a loss to understand the claims of  the Defendant’s Expert and the Service Providers clinicians that their approach is evidence-based.

The Defendant’s Expert might rail that that vast clinical experience is all that is required for effective treatment. Silenced by the prosecuting barrister’s question ‘did it work in this case?’. Following a deafening silence, the prosecuting barrister asks ‘why was EMDR used to treat him, when there was no evidence that he had PTSD?’. To which the Defendant’s barristers retorts ‘it just might have worked’. Moving on to the self-injury and suicide the treating therapists are asked ‘in training were you taught how to identify the thoughts and behaviours behind injury/suicidal behaviour?’ and ‘were you taught how to modify them?’ . The therapist likely replies ‘no but I went on a workshop for DBT post qualification’.  The prosecuting barrister persists ‘were is the evidence that you tackled the thoughts/behaviours behind self-injurious behaviour?’ 

The Judge may well conclude that the Service Providers have let down this teenager by allowing ‘junk science’ to rule, resulting in his following a horrendous trajectory that was reasonably foreseeable. As such they are legally liable.

On Appeal the Service Providers may protest that diagnosis is overrated. But the Appeal Judge comments that the Improving Access to Psychological Therapies claims NICE compliance and the protocols advocated by the latter are largely diagnosis based.  Further the IAPT’s Manual states that its’ clinicians don’t make diagnosis. The Judge opines that this has the smell of deliberate misrepresentation to secure the Government £2 billion a year funding and that the matter should go to the Crown Prosecution Service that deals with criminal matters.

There are those who are avowedly anti-diagnosis but this is much less credible when it comes to depression and the anxiety disorders. Albeit, that a more credible case can be made with regards to ADHD, ASD and Psychosis. With regards to depression and the anxiety disorders (the supposed mainstay of IAPT) the levels of inter-rater reliability using standardised diagnostic interviews have been found to range from very good to excellent [ e.g Tolin et al (2018]. This contrasts with reliabilities of no better than chance when the customary open ended interviews alone are used. The burden of proof is on those who oppose diagnosis to demonstrate reliability of assessment and efficacy of outcome. The case above graphically demonstrates the outcome of unbridled clinical judgements. Psychological therapy has to grow up and address the issue of accountability. 

The case presented above is not exceptional, in a sample of Australian psychologists only 11%  of those working with children or adolescents conducted an evidence-based assessment (the comparable figure for those working with adults was 21%) Moses et al (2020).

Dr Mike Scott