BABCP Response - NICE Consultation January 2022

What Mediates Treatment Outcome in NHS Talking Therapies?



A treatment must directly impinge on a mediator, and the change in the mediator must result in a change in outcome. The mediator and the outcome must be distinct. Thus for example, in the treatment of panic disorder, anxiety sensitivity (the belief that physical and emotional arousal is dangerous) is a mediator of outcome. The treatment, interoceptive exposure (deliberate induction of uncomfortable sensations) dovetails with anxiety sensitivity to affect outcome, the absence of panic attacks. But in                                   NHS Talking Therapies one searches in vain for a mediator – it is all CBT talk, without any substance.

In attempting to apply mediational analysis to NHS Talking Therapies one enters a minefield:

  1. There is no clarity about which disorder/ difficulty is the focus. It could be panic disorder/attacks but there is no reliable mechanism for ruling out disorders beyond the scope of NHS Talking Therapies, such as personality disorders.
  2. Potential mediators are legion, and might include variously post-traumatic cognitions, dysfunctional attitudes and anxiety sensitivity.
  3. There is no evidence that NHS Talking Therapies clinicians have targeted any specific mediator.
  4. In reality NHS Talking Therapy clinicians operate a ‘black box’. Those who have been allowed to penetrate its’ contents Drew et al’s (2021) and Faija et al (2022) have discovered a machine-like process were priority is given to client’s completion of psychometric tests, which do not inform treatment. There is no evidence of the application of mediational analysis.
  5. Outcome is not assessed in NHS Talking Therapies with any hard outcome measure, assessed independently.
  6. All that can be said of NHS Talking Therapies is that time (number of sessions) mediates outcome, but this could be said equally in any possible control group. Time as such is not a relevant theoretical mediator.


NHS Talking Therapies claim to provide cognitive behaviour therapy (CBT) is preposterous, as the hallmark of CBT is the highlighting of disorder specific mechanisms of change and corresponding treatment interventions. It is difficult to escape the conclusion that alleging the provision of CBT is simply a good marketing ploy, enhanced by claims to be able to treat over a million people a year.


Dr Mike Scott