The Great Psychotherapy Debate

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Second edition of Wampold’s, "The Great Psychotherapy Debate," now available

The second edition of Bruce Wampold’s, “The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work,” has been updated and revised to expand the presentation of the Contextual Model, which is derived from a scientific understanding of how humans heal in a social context and explains findings from a vast array of psychotherapies studies.

Wampold book cover

Wampold is the Patricia L. Wolleat Professor of Counseling Psychology at UW-Madison, and the director of the Research Institute at Modum Bad Psychiatric Center in Vikersund, Norway. “The Great Psychotherapy Debate,” is co-authored by the University of Utah’s Zac Imel.  Dr. Zac Imel is a graduate of the department and is currently an Assistant Professor in the Department of Educational Psychology and an Adjunct Assistant Professor of  Psychiatry at the University of Utah.

 Preface

 When one publishes a book with the word debate in the title, one must be prepared for rebuttals.  In science, rebuttals are best presented as evidence.  In the 13 years since the first edition, there have been many arguments about what makes psychotherapy work, best characterized by a debate between proponents of evidence-based treatments and proponents of common factors.  This debate often mischaracterizes one side or the other, with more than a few instances when rhetorical accusations have predominated, rather than evidence. 

Rhetoric does not keep me up at night, but evidence surely does. And since the first edition, there have been many reasons for sleepless nights. As Zac and I discuss in this volume, psychotherapy evidence has proliferated since the first edition.  The number of psychotherapy clinical trials and meta-analyses of these trials has increased exponentially. There is more evidence now for the effectiveness of psychotherapy now than ever before. Would that evidence trend toward showing the scientific folly of the Contextual Model that I proposed in 2001?  If so, then the Contextual Model would fall on the scrap heap of perfectly rational, but empirically unsupported, theories, including chemical theories of fermentation (spontaneous generation), light propagation through aether, and a static universe (Einstein’s Universe).  Yet, the research conducted in the last decade and a half has not produced evidence that seriously threatens the Contextual Model—indeed, the evidence for the Contextual Model is an order of magnitude stronger than it was in 2001.

In the preface to the first edition I spoke about the meaning of psychotherapy for me personally and dedicated the book in part to my therapist.  Sadly, some of have used this intimate story to say that my work is biased and should not be trusted.  So, let me be clear about this—as is true of all humans, I do indeed have biases.  However, one hallmark of science is that we intentionally put aside our biases aside and attend rationally to evidence.  Moreover, the scientific endeavor is a correcting system in that evidence in the end will prevail and theories will be abandoned, despite their ability to attract adherents, should the evidence by sufficiently compelling.  As with all theories, the current iteration of the Contextual Model will be modified as anomalies are detected-- in the coming decades evidence will likely emerge that both clarifies and complicates components of the model.  In this process, my allegiance is to the evidence and there is no disgrace in having one’s theory ultimately to be found in the same dustbin as Einstein’s Static Universe. 

This edition of the Great Psychotherapy Debates differs from the first edition in several ways.  Of course, the research corpus is updated and the various chapters reflect the latest evidence.  The first chapter now presents a brief history of medicine and psychotherapy to put the current debate into a proper perspective.  In 2001, The Contextual Model I proposed was just emerging from the work of Jerome Frank.  During the last decade, the model has expanded based on social science research—the expanded model is presented in Chapter 2. As in the previous edition, there is a chapter (Chapter 3) that presents what evidence is to be considered and then discusses the conjectures of the Medical Model and the Contextual Model.  As in the first edition, there are chapters that examine the evidence for absolute efficacy (Chapter 4), relative efficacy (Chapter 5) and therapists effects (Chapter 6).  In the first edition, evidence related to general effects was limited to a discussion the therapeutic alliance. We have expanded this section to also include how placebos induce powerful expectations as well as several other therapeutic factors hypothesized to be powerful in the Contextual Model (Chapter 7).  Chapter 8 reviews the literature on the importance of specific ingredients.  Chapter 9 makes conclusions related to theory, practice, and policy. 

Books have authors.  But authorship reflects an amalgamation of influences.  To a large extent, my work was spawned from discussions with students and collaborations with colleagues around the world.  Zac Imel, from his first days as my doctoral advisee over a decade ago, has challenged me to think deeply about the issues discussed in this edition and expand my methodological expertise.  He would bring articles and books to me: “You have to read this!” and “We have to learn new methods to understand this issue,” his restless mind collecting and synthesizing information from a variety of spheres.  This edition has continued our intellectual collaboration, mutually stimulating and rewarding.

BEW, Madison, Wisconsin, 1 April 2014

 

Quite unintentionally, my psychology training began in small groups that were a part of church youth camps in the Red Rock Canyons of Oklahoma. I observed the work of talented group leaders who worked to replace emptiness and shame with acceptance and support. While many of my peers were taken with spiritual explanations for these experiences, in me they awoke an appreciation for open and emotionally charged relationships, providing an enduring template that continues to guide my relationships and informs my clinical work.

The intervention we discuss in this book is still mostly a human conversation – perhaps the ultimate in low technology. Something in the core of human connection and interaction has the power to heal. Ironically, the unavoidable complexity of unstructured, emotional dialogue poses an immense challenge to scientists who wish to know why it is that conversations with certain characteristics lead to improvements in psychological well being, decreases in distress, and recovery from profoundly disabling mental health problems – while other conversations do not.

As we complete this second attempt to summarize the existing evidence for a general model of psychotherapy as outlined by the Contextual Model, we are confronted with interesting times for psychotherapy as a science and profession. Patients prefer psychotherapy as a first line treatment for many problems, but psychotherapy continues to decrease as an overall percentage of mental health care. There is more evidence for the effectiveness of what therapists do and how they do it than ever before, but much remains unknown. Technology has revolutionized almost every aspect of human life, transforming science, medicine, entertainment, journalism, and social interaction. However, our current gold standard for evaluating the process of change in psychotherapy - human behavioral coding of patient-provider interactions – is based on 70 year old technology first used by Carl Rogers and his students. Simultaneously, computer scientists and electrical engineers develop techniques that can model the words in all published books and automatically recognize speech from acoustic signal. The American Psychological Association released a general statement on the effectiveness of psychotherapy, but many contend that advocating for the effectiveness of psychotherapy generally is like talking about the effectiveness of “drugs.” Instead, they argue we have are scores of specific evidenced based treatments with demonstrated effectiveness. The Veterans Health Administration launched one of the largest psychotherapy quality improvement initiatives in history by disseminating specific psychotherapies into mental health specialty clinics, but regular monitoring of patient outcomes or provider behavior is mostly absent in community settings. 

I am the son and grandson of accountants, engineers, and teachers and thus it is not surprising that my rebellion into the practice of psychotherapy led quickly back to an emersion in numbers and the academy. I first read the Great Psychotherapy Debate after graduating from a small liberal arts college where I thrived in the intellectual space between scientifically oriented psychology and a pluralistic religious studies department with professors who often shared lunch (and maybe a polite argument or two). In psychotherapy, I was quickly frustrated by what I saw as a glut of “true believers” and the persistence of theoretical camps that seemed independent of the evidence. Thus, I was quickly taken by the parsimony of the common factors approach outlined in the book, and Bruce’s devotion to data and the scientific method. Upon arrival in Madison in 2003, I quickly began what I have come to recognize as an unusually close and productive collaboration working and thinking about how to make sense of the beautiful mess that is psychotherapy data. Bruce encouraged my natural skepticism and curiosity, and Monday morning espressos were a time to poke holes in our own theories (as well as those of others, of course). I like to think my contributions to this volume began during those meetings.

ZEI, Salt Lake City, Utah, April 2014




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