Since 1996, the short list of empirically validated treatments originally provided by the Division of Clinical Psychology (although never endorsed by the American Psychological Association as a whole) has been vastly expanded and augmented by numerous other such lists, provided by organizations such as the Society of Clinical Child and Adolescent Psychology, The Cochrane Collaboration in Great Britain, the American Psychiatric Association, and evidence-based medicine websites such as Uptodate.com. The lists from these sources mostly agree about which treatments qualify; most are cognitive-behavioral approaches. Today, lists of treatments that have achieved the status of "well established" have grown exponentially, with groups of approved approaches now established for almost all DSM disorders, including agoraphobia, generalized anxiety disorder, depression, borderline personality disorder, sexual dysfunction, and alcohol abuse. Several states, including Washington, have taken the next step of mandating the use of only research-supported therapies in some of their mental health and juvenile justice programs. In addition, several countries, including Germany and the Netherlands, have tied payment of service to the practice of research-based treatments. Not surprisingly, increasing numbers of insurance companies are requiring, or considering requiring, practitioners to use research-supported methods to be reimbursed.

The good news in all this for psychotherapy is that our field has established a track record of broad empirical legitimacy, which will be crucial if we're to continue to have a place in the healthcare system. Study after study has shown that, in addressing a wide array of DSM disorders, psychotherapies work at least as well as, and often better than, medications. Nevertheless, some critics insist that for an approach to receive approval as being research-based has less to do with its effectiveness than with whether it's been studied frequently. They maintain that, as a result, innovative methods and potentially valuable clinical tools not recognized by academic researchers may be harder to incorporate into practice, restricting the flexibility and creativity of ordinary clinicians. In their view, with all the constraints limiting research funding today, the current system is in danger of creating a closed circle of favored approaches as attention comes to be increasingly limited to whatever has been already demonstrated to be effective, leaving new methods, however potentially valuable, outside the purview of research investigation.

An Alternative Paradigm

In 2002, Bruce Wampold of the University of Wisconsin, one of the foremost critics of lists of established clinical practices, published The Great Psychotherapy Debate, a book that raised fundamental questions about the entire enterprise of psychotherapy outcome research. He argued that, despite an emphasis on comparing methods, the evidence showed that differences between treatment approaches accounted for little of the overall impact of successful treatment. Instead, what his metanalyses revealed was that the characteristics of the therapist and the client, independent of specific treatment approaches, and the relationship factors mediating their connection, had far more impact than the treatment factors themselves. He suggested that there's no evidence that research-supported therapies work better than what he called bona-fide treatments (real therapies conducted by real therapists, rather than treatments in which therapists do virtually nothing), and that metanalyses find no differences in outcome when bona-fide treatments are compared.

Wampold's elaborate statistical method may have given his critique special weight, but many others have voiced reservations about the field's way of bestowing its official seal of approval on a select group of approaches. Among the commonest criticisms are that studies of empirically approved therapies ignore cultural or, for that matter, any sort of client factors, lack attention to differences between therapists who apply the treatments (in some prominent studies, the difference in impact between therapists has been much greater than that between treatments), almost exclusively focus on short-term therapies, and consistently find that the treatment favored by the investigator does better than other treatments—the notorious "allegiance effect."

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