LAUSR

In the 1990s, claims for the superiority of a particular treatment disturbed me. I was trained in mathematics and the sciences, so my perspective on psychotherapy was saturated by the scientific method —clearly, the claims for superiority were more advocacy than science. Additionally, my personal experience with and preferences for psychotherapy were not oriented toward symptom focused methods. Finally, there is part of my personality that made it difficult to accept a dictate from powerful figures, to be quite frank (which, I am sure will not surprise anyone who knows me). To examine claims of superiority, my students and I undertook a meta-analytic examination of comparisons of psychotherapies intended to be therapeutic (Wampold et al., 1997). Not one fragment of evidence for treatment differences emerged. Misconceptions about the meta-analysis abound. Not once have I claimed that this meta-analysis proves that the common factors are responsible for the benefits of psychotherapy. As Cuijpers (in press) noted, the equivalence of treatments does not infer that the so called common factors are the mechanisms of change, although it suggests that this may well be the case. Based on research in various areas of psychotherapy (e.g., relationship factors, alliance, and therapist effects), placebo effects, medicine, and social psychology, there is extensive support for the conjecture that evolved human characteristics are involved in social healing, of which psychotherapy is a well-developed example (Wampold, 2021; Wampold & Imel, 2015). However, a vital component of any viable intervention is a coherent, cogent (within the cultural context), and believable treatment administered by a competent and persuasive clinician. Although I agree enthusiastically with Westra (in press) about the necessity to improve relationship skills, particularly in interpersonally challenging situations, the focus on the patient’s problems and the patient’s efforts toward progress towards their goals, within a believable treatment context, is essential as well. Simply relating to a patient without a coherent treatment and work toward goals is as deficient as delivering a treatment, say following a treatment manual, without the necessary relational skills. Why is the field so resistant to the notion that a believable treatment delivered by an interpersonally skilled clinician is essential—both, not either or. Finally, I am skeptical of improving services by implementing purportedly superior treatments in a system of care, based on a randomized clinical trial, because (a) the results often defy reasonable explanations (no differences at six months but differences at 12 months; Barkham, in press), (b) implementing results from clinical trials in other contexts is fraught with difficulty (Deaton & Cartwright, 2018), (c) psychotherapy trials rarely if ever are replicated (Frost et al., 2020), (d) differences among therapists, due to their clinical skills, are more important than differences among treatments, even if a treatment is demonstrably (but marginally) better (Wampold & Imel, 2015), and (e) such implementation reduces therapist and patient preferences and leads to therapist discouragement. The designation of the RCT as the gold standard of psychotherapy research has set us back decades—to wit, identify one clinically actionable conclusion from RCTs, which by the way have cost hundreds of million of dollars.