‘Thanks, but no thanks’: The public's response to engagement with NHS Talking Therapies – a salutary tale? 2024 Scott

Sly Saint

Sly Saint

Senior Member (Voting Rights)
Abstract
Objectives
The English NHS Talking Therapies has been hailed as a world leader in demonstrating outcomes, generating 1.76 million referrals in the year 2022–2023, with a claimed 49.9% recovery rate, but there has been a dearth of independent evaluations. Importantly, there have been no published data on those who only attended one assessment/treatment session. This also applies to public services internationally. The issue of the acceptability of psychological treatment has not been addressed.

Method
The user-friendliness of NHS Talking Therapies was examined, drawing on unpublished data revealed following a Freedom Of Information request response to the author in June 2024. These data are set alongside the service's published data to give a more comprehensive view of real-world outcomes and whether it should be a template for other countries to follow.

Results
Almost half (45%) do not complete treatment, and for completers, the results are no better than for placebo. The diagnostic status of almost a third (29.1%) who attend just one session is unknown. The numbers of people who attend one assessment/ treatment session is approximately half of those who attend two or more treatment sessions, but the ratio varies by disorder.

Conclusion
NHS Talking Therapies' engagement difficulties casts serious doubt on the service's claim to be a ‘world beater’. There is no evidence that NICE-compliant evidence-based psychological treatments have been delivered. While this model has been widely adopted in the UK, this should not be transferred to other service systems without contextualisation and evidence on whether/how some of its components could be implemented in those settings.

Implications for practice and policy
  • There ought to be a publicly funded, independent study of the effectiveness of NHS Talking Therapies for anxiety and depression.
  • Practitioners ought to become aware of the scarcity of evidence supporting current provision and advocate for a service, that could, at least in principle, deliver real-world outcomes from a client's perspective.
‘Thanks, but no thanks’: The public's response to engagement with NHS Talking Therapies – a salutary tale? - Scott - Counselling and Psychotherapy Research - Wiley Online Library
 
One in three of those who attend NHS Talking Therapies sessions do so for only one session, this led to the title of my just published paper Scott (2024). Following a Freedom of Information (FOI) request, I obtained data on those attending just one assessment/treatment session. The Service has chosen to focus on those who attend two or more sessions and its’ recovery claims refer to this population. But this is an incomplete picture as there has been a ‘haemorrhaging’ before treatment.

The mean number of treatment sessions attended is 7-8, but this means that half of those treated have less than 7-8 sessions. But NICE recommended treatments for depression and the anxiety disorders are typically for 12+ sessions. Thus at least half those treated by NHS Talking Therapies have a sub-therapeutic dose of treatment. This makes the Services claim for comparable effectiveness (50% recovery) to randomised controlled trials, where there is no ‘haemorrhaging’, preposterous, pure marketing.

The paper also reveals that the Service has a claimed recovery rate for ‘mixed anxiety and depressive disorder’, that is comparable to other disorders. But there is no NICE recommended protocol for this disorder, it is therefore impossible for it to be NICE compliant. This suggests NHS Talking Therapies get the same ‘result’ however they label a disorder and whatever intervention they deliver. In Scott (2024) I suggest that the Service has capitalised on a placebo effect – the results reflect, simply a combination of: attention, raised expectations, improvement with time and the clients desire to please their therapist.
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full post on his blog
NHS Talking Therapies 'Thanks, But No Thanks' - CBT Watch
 
I was referred to IAPT nearly 15 years ago. I got a few sessions out of it but the therapist was useless.

What annoyed me the most was the "advice" I got from the therapist... I couldn't afford to follow the advice in one section (Edit : of my "treatment"). And in another I would have needed a lot more help to go through with it than I actually got.
 
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The paper said:
NHS Talking Therapies' engagement difficulties casts serious doubt on the service's claim to be a ‘world beater’.
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Ah, but this is a race to the bottom. So it is world beating, and the beatings will continue until morale appears to improve based on half of half of users giving answers generic biased questionnaires slightly differently, as long as you give the data a good waterboarding session or two.

Although I don't think much of the suggestion that failure in outcome may have to do with lack of 'dose' or not following evidence-based medicine. Even in trials they don't get any better than this, the vast majority seeing no benefit is part of the intention-to-treat equation, although it makes the initial target of 50% obviously fraudulent. From PACE the very best they can boast for is 15% check some meager subjective changes on questionnaires, with zero objective benefits, so this is right there in the numbers they seek. They just lied about the whole thing, knowing that once in place it would be too hard to stop. This ideology depends mainly on momentum, on compromising resources in ways that are too embarrassing to stop.

It's quite something that there is zero interest in accurately auditing this, and you can bet that anyone proposing that would be shut down very quickly. Says everything about how intensely, hell exclusively, political this psychobehavioral ideology is. Given what the UK government announced recently, I expect a significant investment in growing this pile of garbage. It's not as if there's ever a point at which anyone involved in this will start asking questions or raise issues. A con job is all about expressing confidence in an illusionary outcome that has zero chance of happening.
 
Arnie Pye said:
I was referred to IAPT nearly 15 years ago. I got a few sessions out of it but the therapist was useless.

What annoyed me the most was the "advice" I got from the therapist... I couldn't afford to follow the advice in one section. And in another I would have needed a lot more help to go through with it than I actually got.
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That sounds pretty dangerous to me because it’s … well a different word from disability discrimination but beyond insensitive and when you add it on top of the gaslighting ‘you’re ill because you didn’t work hard enough (which isn’t true but no one stops to hear you crrect them with your truth) attitude’ we’ve had levied at us I’m afraid but it’s enough to tip people over the edge as another callousness of you don’t matter, aren’t heard and we don’t care to hear from you.

Which is the opposite of why talking therapy of any kind was ever invented or used. It shouldn’t be to ostracise people to their face. Whether deliberate or unknowingly.

of course the other issue with offering this in the way it has been is it profits from what everyone knows about the Uk health system which is that coercion and ‘don’t upset the staff otherwise it will affect future access to treatment’ is what everyone gets taught

which should never have existed but does and could have been unpicked and knocked on the head to use notes vindictively so that astounds me it still happens /people aren’t reassured it doesnt decades on

the ‘thanks but no thanks’ title is clever fir capturing that’s the harshest anyone is going to safely get even from the ‘most free to be honest’ patients
 
rvallee said:
Ah, but this is a race to the bottom. So it is world beating, and the beatings will continue until morale appears to improve based on half of half of users giving answers generic biased questionnaires slightly differently, as long as you give the data a good waterboarding session or two.

Although I don't think much of the suggestion that failure in outcome may have to do with lack of 'dose' or not following evidence-based medicine. Even in trials they don't get any better than this, the vast majority seeing no benefit is part of the intention-to-treat equation, although it makes the initial target of 50% obviously fraudulent. From PACE the very best they can boast for is 15% check some meager subjective changes on questionnaires, with zero objective benefits, so this is right there in the numbers they seek. They just lied about the whole thing, knowing that once in place it would be too hard to stop. This ideology depends mainly on momentum, on compromising resources in ways that are too embarrassing to stop.

It's quite something that there is zero interest in accurately auditing this, and you can bet that anyone proposing that would be shut down very quickly. Says everything about how intensely, hell exclusively, political this psychobehavioral ideology is. Given what the UK government announced recently, I expect a significant investment in growing this pile of garbage. It's not as if there's ever a point at which anyone involved in this will start asking questions or raise issues. A con job is all about expressing confidence in an illusionary outcome that has zero chance of happening.
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It’s worrying what a political construct / initiative it seems to be in how its run and hierarchy (and how it’s assessed and what it even thinks its mission is - it doesn’t seek to understand those dumped into it, very strong beliefs in whatever this one-way thing is ‘being what they all need’ without evidence, it seems just a few individuals' personal idea then sold to others)

not what any mental health care should be at all when you think about the responsibility that should be implicit in meddling with people who might be in very precarious situations in life - it feels it comes with as much risk of harm as of doing any good (which I actually struggle to stretch for examples where it would be if any even part use)

psychology might have struggled to demonstrate/measure something which needs to be individual to the situation snd involves personal overall needs (like eg if they are ill or have asd then that should be borne in mind in matching type and length of any treatment for anything else) ie it’s all about ‘matching’ cause and need to offering. But that [matched offering that is genuinely led by the needs of the situation] was always the conclusion of what ‘worked’ and then you add in how important gelling with the person you get allotted as a counsellor of therapist - which is just common sense.

This project was all about trying to sausage machine something which all the ‘good’ came from the adaptation to these needs and the issue itself

what it seems the misguided people who did this have done is the equivalent of taking the old school idea of a GP being able to ‘hear the whole list of symptoms, and know where to send people to as likely underlying medical issue’ into them only being able to offer one thing and how they offer it having been limited too, whatever ailment they have, so don't bother diagnosing them too closely first.

the sad thing was it was all just about proving how you ‘could’ get stats if you pretended everyone had the same. By giving everyone the same offering - but that phrase ‘equal isn’t always fair’ or to be more precise you aren’t offering everyone ‘the same’ if some people get therapists who don’t understand their disability others have someone who is sane demographic and it’s a lucky match, nevermind adding in those who really had something that needed totally different practical support and got CBT instead.

so beyond it being a waste - just I wonder what it thinks it’s offering. It feels like an exercise in discrimination because it turned on its head the most important element of psychology- the ‘listening’ and then the ‘matching’ and starting with ‘understanding the situation’

I have a worry they’ve created the equivalent of the friend or rubbish counsellor who just lets someone talk thinking they’ve ticked the box and it’s their turn to speak for a few minutes now, but aren’t listening at all. Which is invalidation

and of course none of these key points appear in what they are measuring.
 
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It is a world-beating intervention - at achieving its purpose, which is to reduce demand on the NHS by getting people to stop bothering doctors.

This “treatment” has the unusual quality of working whether you participate or not. If you attend your sessions, you stop bothering doctors because the sessions teach you that doctors cannot help you because you are the problem. If you don’t attend your sessions, you stop bothering doctors because you have observed that the NHS has nothing useful to offer you. Either way, you stop bothering doctors.

I would be interested to know exactly how effective IAPT/NHSTT is at achieving this outcome of fewer NHS contacts. I suspect even a rejected referral reduces future NHS contacts. And what about the effect of a previous IAPT referral on NHS contacts for unrelated conditions? But I fear such a study would be enthusiastically touted as a reason to increase its use.

This is the hollowing out of an institution built on a great promise - to make ill people well and for the cost to be shared across all of us - and its replacement with manipulation and lies. It is incredibly depressing, but it will continue until it is proven to be more expensive than honesty.

The really interesting question is whether this intervention is more effective at achieving its goal than non-intervention. Why offer anything at all? Why not go back to the pre IAPT days of telling patients to get lost? IAPT was sold to the NHS on the basis that it would assist caring GPs who might otherwise refer patients to secondary care, and it probably does. IAPT/NHSTT also seems to be used within secondary care to off-roll patients without GPs objecting. But is that a net financial gain to the NHS? I’m not so sure.

Government was also told that this pseudo-treatment would get people back to work and reduce costs to society generally. Here again, more studies are needed. Has the use of pseudo-treatment expanded to the point that it’s pulling in large numbers of people whose conditions could be treated for real? And does it pull in enough people for whom CBT is effective to pay for the cost of offering it to large numbers of people for whom it is useless?

A reasonable hypothesis is that people who are likely to be helped by CBT will be more likely to volunteer for it. So it would be interesting to see a pilot where NHSTT is available for self-referral (like physio in some areas) but where when offered by doctors it is always offered honestly and alongside the offer to do nothing: we have nothing further medical to offer you, but some doctors believe that symptoms like yours can be caused by psychological distress and may respond to CBT focusing on a positive attitude. That could perhaps achieve similar demand reduction at considerably less cost - and with the benefit that it would be honest.
 
dratalanta said:
It is a world-beating intervention - at achieving its purpose, which is to reduce demand on the NHS by getting people to stop bothering doctors.
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Judging by the news from the UK I have seen over the years, I'm pretty sure it has not achieved that purpose, not even a bit. But then again objective outcomes are for nerds, nothing a biased questionnaire can't be used to extract some secondary feel-good trend toward something or another.
 
rvallee said:
Judging by the news from the UK I have seen over the years, I'm pretty sure it has not achieved that purpose, not even a bit.
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No. But adding friction might be enough.

If you can blame it on the last government and your government's unlikely to be in power for the 10 years it would take to start turning the ship round, all that's required of you is a bullish slogan for the conference and being photographed talking to some nurses with your sleeves rolled up.
 
rvallee said:
Judging by the news from the UK I have seen over the years, I'm pretty sure it has not achieved that purpose, not even a bit. But then again objective outcomes are for nerds, nothing a biased questionnaire can't be used to extract some secondary feel-good trend toward something or another.
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That’s why what is needed is to expand the programme to more patients…
 
IAPT, Increasing Access to Psychological Therapies, “the most ambitious programme of talking therapies in the world”, now called NHS Talking Therapies, was instigated by New Labour in 2005/6.

The IAPT designer Baron Richard Layard (LSE Economist) proclaimed 'CBT for All', even presenting CBT as the 'cure' for the unemployment figures in 2006/8. IAPT was/is a one size fits all cure-all for anxiety and depression that has grown and grown in size and cost - but has never delivered better mental health.



Damning reports on IAPT from 2021:


'NHS mental health therapists pressurised to exaggerate success rates, expert claims'

'‘Actual human experience was secondary to creating data that would shore up the evidence base for the model to guarantee further investment,’ says one'


'The provision of psychological treatment on the NHS has undergone an “Uberisation”, in which counsellors are pressurised to exaggerate their success in treating patients, a conference has heard.

Elizabeth Cotton, of Cardiff Metropolitan University, an expert in mental health at work, said that more than four in 10 – 41 per cent – of therapists working for the NHS’s talking treatments programme had been asked to manipulate data about patients’ progress.'

The action is designed to improve the scheme’s apparent achievement rates, although NHS chiefs insist patients’ views are recorded when therapists are not present.'

'IAPT plans should allow the number of people with anxiety disorders or depression who can access talking therapies increase by an extra 380,000 per year to reach 1.9 million by 2023-24, under NHS plans.

But Dr Cotton, an adult psychotherapist who has written a book on working in health and social care, says the pressure on therapists was such that some had been encouraged by their managers to coach patients to give positive answers to questionnaires.

Patients were urged to repeat the questionnaires until a positive response was obtained, she told the British Sociological Association conference on work.

Where patients discharged themselves without notifying the NHS, the therapist was encouraged to fill in data sheets on their behalf to reflect a positive outcome, said Dr Cotton.....'



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'In another survey of 650 IAPT employees, carried out in 2019, 41 per cent said they had been asked to manipulate data.

One therapist had reportedly been advised by their manager that “I could complete forms on behalf of clients to get the best results”.

Another said: “Actual human experience was secondary to creating data which would shore up the evidence base for the model to justify the economic argument and guarantee further investment.

“The whole system represents a big self-reinforcing loop relating to success in terms that had been self-defined by the system.”

Dr Cotton warned the downgrading of therapy “into a standardised, manualised, and now digital model” had “opened up the doors for the ending of highly experienced clinical work in the public sector”.

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https://www.independent.co.uk/news/health/nhs-therapists-patients-manipulate-data-b1908629.html

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Service assessment of this giant government scam seems to follow the usual (lack of) standard we have seen out of the biopsychosocial school of thought: describe what they're doing and how they do a lot of it. Doesn't matter that it's useless, this is what they do and this is how much of it they are doing it. Whether something works or not is now entirely irrelevant, it's not even part of consideration. Maybe it never has, frankly.


Almost 70,000 people with mental health issues were given employment support last year as part of the NHS Talking Therapies Programme – up nearly two-thirds on the year before, latest NHS figures show.

New data also shows almost 2 million referrals (1.8 million) to Talking Therapies were made last year, with more than 1.2 million people starting treatment.

https://www.england.nhs.uk/2025/01/nhs-supports-thousands-more-people-back-into-work/
 
An IAPT insider blows the whistle.

23rd August 2022
'A Psychological Wellbeing Practitioner Breaks The Wall of Silence'

'The short end of it all is that being a PWP is very similar to run of the mill call-centre, telemarking and sales job. No matter what the average worker says “but we do a great service”, I feel they are a tad bit delusional. I do not blame them. To survive this job you either need to resort to trickery or delude yourself that you are doing something worthwhile. The latter group probably have a mortgage to pay. We are told what to say, how to say it, when to say it and constantly told “it’s all about the numbers/targets”.

We also have a script, which is very similar to those phone contract customer service people. The hellish brilliance of IAPT is that if the targets are not reached, the organisation uses an attributional bias to blame the “practitioners”/miners and not the “system”/pit owners and fellow travellers.'


'Pre-IAPT there were “mental health workers (MHWs)”, and the public had some idea of the discharge of this particular, professional role. But from 2008 MHWs became Psychological Wellbeing Practitioners, leaving the public and professionals scratching their head as to what the designation might mean. Where PWPs to be regarded as professionals or not? Despite the inherent confusion, I followed my work’s advice to the letter: did the questionnaires, kept the original scores and ploughed onwards. However, what I noticed is that many clients (I dislike using the term patients because it doesn’t feel like we are official clinicians either) were finishing treatment or dropping out with “high scores”. It was not too long until I was interrogated for a below 50% recovery rate.'


'The recovery rate of 50% is impossible unless one manipulates the numbers or manipulates the clients to be compliant. I guess, good old fashioned “sales tactics” (convincing people they need a product or that they are better than when they started). Of course, the Managers did not care. '


'Working in IAPT is robotic: clicking tabs, ticking boxes and collecting numbers – a de-humanising experience. There is little to encourage anyone to become a PWP. In fairness I suppose, at least a personal level, I have survived lockdown financially. But the service has in effect been “cooking the books” and making the company look good. I fear for the mental health not only of the ambassadors but for that of clients past and to come.

I am off to other pastures, can you wonder at the turnover?'

http://www.cbtwatch.com/a-psychological-wellbeing-practitioner-breaks-the-wall-of-silence/

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I'm not surprised by this at all. Last year I was referred twice and both times I backed out after filling out the forms/survey thing. It was obvious from the questions they wanted to solve a very specific issue and it didn't even take into account personal situations like chronic illness.
 
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