Page 1

The second edition of The Great Psychotherapy Debate 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 psychotherapy studies. This model provides a

compelling alternative to traditional research on psychotherapy, which tends to

focus on identifying the most effective treatment for particular disorders through

emphasizing the specific ingredients of treatment. The new edition also includes

a history of healing practices, medicine, and psychotherapy; an examination of

therapist effects; and a thorough review of the research on common factors such

as the alliance, expectations, and empathy.

Bruce E. Wampold, PhD, ABPP, is the Patricia L. Wolleat Professor of Coun-

seling Psychology at the University of Wisconsin–Madison and director of the

Research Institute at Modum Bad Psychiatric Center in Vikersund, Norway.

Zac E. Imel, PhD, is an assistant professor with the counseling psychology

program in the department of educational psychology and an adjunct assistant

professor in the Department of Psychiatry at the University of Utah.

The Great Psychotherapy Debate

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The Evidence for What Makes

Psychotherapy Work

Second Edition

Bruce E. Wampold and

Zac E. Imel

The Great Psychotherapy

Debate

Second edition published 2015

by Routledge

711 Third Avenue, New York, NY 10017

and by Routledge

27 Church Road, Hove, East Sussex BN3 2FA

Routledge is an imprint of the Taylor & Francis Group, an informa business

© 2015 Bruce E. Wampold and Zac E. Imel

The right of Bruce E. Wampold and Zac E. Imel to be identified as authors

of this work has been asserted by them in accordance with sections 77

and 78 of the Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this book may be reprinted or reproduced

or utilised in any form or by any electronic, mechanical, or other means,

now known or hereafter invented, including photocopying and recording,

or in any information storage or retrieval system, without permission in

writing from the publishers.

Trademark notice: Product or corporate names may be trademarks

or registered trademarks, and are used only for identification and

explanation without intent to infringe.

First edition published by Routledge 2001

Library of Congress Cataloging-in-Publication Data

Wampold, Bruce E., 1948–

The great psychotherapy debate : the evidence for what makes

psychotherapy work / by Bruce E. Wampold and Zac E. Imel. —

Second edition.

pages cm

Includes bibliographical references and index.

1. Psychotherapy—Philosophy. 2. Psychotherapy—Evaluation.

I. Imel, Zac E. II. Title.

RC437.5.W35 2015

616.89′14—dc23

2014032867

ISBN: 978-0-8058-5708-5 (hbk)

ISBN: 978-0-8058-5709-2 (pbk)

ISBN: 978-0-203-58201-5 (ebk)

Typeset in Baskerville

by Apex CoVantage, LLC

To all of my collaborators, personal and professional, many

of whom have made sacrifices so that this revision could be

completed. BEW

To KT, Jiajia, and Lulu. ZEI

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Contents

Preface

viii

1 History of Medicine, Methods, and Psychotherapy:

Progress and Omissions

1

2 The Contextual Model: Psychotherapy as a Socially

Situated Healing Practice

37

3 Contextual Model Versus Medical Model: Choosing

a Progressive Research Programme

62

4 Absolute Efficacy: The Benefits of Psychotherapy

Established by Meta-Analysis

82

5 Relative Efficacy: The Dodo Bird Still Gets It

114

6 Therapist Effects: An Ignored but Critical Factor

158

7 General Effects: Surviving Challenges and Anticipating

Additional Evidence

178

8 Specific Effects: Where Are They?

213

9 Beyond the Debate: Implications of the Research

Synthesis for Theory, Policy, and Practice

255

References

279

Index

317

When one publishes a book with the word debate in the title, one must be pre-

pared 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 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 psychother-

apy for me personally and dedicated the book in part to my therapist. Sadly,

some 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 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 be 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

Preface

Preface ix

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 Debate differs from the first edition in

several ways. Of course, the research corpus is updated and the various chap-

ters reflect the latest evidence. The first chapter now presents a brief history

of medicine and psychotherapy to put the current debate into proper perspec-

tive. 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 of 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 exper-

tise. 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 collect-

ing and synthesizing information from a variety of spheres. This edition has

continued our intellectual collaboration, mutually stimulating and rewarding.

BEW, Madison, Wisconsin, April 1, 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 apprecia-

tion for open and emotionally charged relationships and provided an enduring

template that continues to guide my relationships and inform 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 connec-

tion 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

x Preface

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, medi-

cine, 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 have developed 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 effective-

ness of “drugs.” Instead, they argue we have scores of specific, evidenced-based

treatments with demonstrated effectiveness. The Veterans Health Administra-

tion 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 back to an immersion 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 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

Examining only the current state of affairs in any field reveals recent trends but

can obscure other critical issues. And often it is what is left behind in our efforts

to attain progress that reveals much about the field. Psychotherapy, shaped by

context, actors, and allied fields (particularly medicine), is no exception. The

pursuit of progress—or maybe better said, the inevitable process of progress—

comes with a cost. It may well be that what is cast off as archaic is actually the

essence, and what is retained is a façade. On the other hand, innovation and

progress can be achieved, and nostalgically clinging to the past can be damag-

ing. In this book, a critical examination of the progress in psychotherapy is

undertaken with attention to the hidden, forgotten, and ignored factors, as well

as to the current practices, policies, and research.

A romantic notion is that progress is a result of knowledge—evidence driv-

ing innovation and practice. However, the modern view is that events are the

result of human action, and human action is influenced by a myriad of factors,

of which evidence is only one. But then, even the notion of evidence is prob-

lematic, as evidence is the interpretation of a pattern of data—interpretation is

a human cognitive task subject to biases, power, methods, and constraints. The

social sciences are particularly vulnerable to these vectors as precision is not

great, replication is infrequent, and the subject matter is imbedded in cultural,

political, and fiscal contexts. In most instances, psychotherapy exists within a

health delivery system that exerts further pressure to progress along a narrow

corridor. So constrained, psychotherapy exists as it is, but its future is to be deter-

mined, primarily by the actors whose influence is most boldly exerted. This

book’s thesis, which is outside the canonical view yet built upon the very evi-

dence collected within that canon, provides an alternative course for the future.

The course, which was abandoned some time ago and is updated here under

the name “The Contextual Model,” may, if we can be so bold, be the one that

has more potential to benefit patients than the course presently being pursued.

Before the evidence can be presented for a contextual view of psychotherapy,

there are certain consequences from history that need to be fully understood.

How did we get here? And what was omitted to make certain progressions? Sev-

eral intertwined stories need to be examined: the stories of medicine, research

Chapter 1

History of Medicine, Methods,

and Psychotherapy

Progress and Omissions

2 History of Medicine, Methods, and Psychotherapy

methods (particularly clinical trials), and psychotherapy. Of course, each of these

histories could fill a volume on their own (indeed, there are several volumes on

each), but abbreviated versions are sufficient to take notice of important elements.

Medicine

Medicine is the dominant healing practice in Western cultures. It is the appli-

cation of scientific knowledge to cure disease, alleviate physical suffering, and

prolong life. However, modern medicine is a recent invention and one that

evolved from a tradition of healing practices, most of which medicine would

rather not claim as antecedents.

The Origins of Medicine as a Healing Practice

Healing practices appear in the earliest humans and characterize, in an impor-

tant way, the essential nature of humanness:

According to Sir William Osler (1932), the desire to take medicine is one

feature that distinguishes hominids from their fellow creatures. . . . Although

nothing is known about the earliest medications or about the first physi-

cian, historians date the earliest portrait of a physician to Cro-Magnon

times, 20,000 B.C. (Haggard, 1934; Bromberg, 1954). This horned tailed,

hirsute, and animal-like apparition had great psychological effect, and it is

likely that the treatment used was simply a vehicle for the psychological or

placebo effect and was without any intrinsic merit (Model, 1955).

(Shapiro & Shapiro, 1997b, p. 3)

Indeed, it is impossible to identify historically a civilization in which med-

icines, rituals, and healers were not central features of the culture (Shapiro

& Shapiro, 1997b; Wilson, 1978). As societies evolved, the human mind was

predisposed to generate explanations of physical, mental, and somatic phe-

nomena (Gardner, 1998)—the particular explanations differed by culture and

have evolved over time—but the art of using the explanations to create and

apply treatments—that is, the practice of healing—has spanned both culture

and time. Indeed, the nature of the healing practice is a large component of

the description of any culture, as healing and other cultural practices are so

intertwined. The Pythagoreans suggested that the body was composed of

four humors (viz., blood, phlegm, yellow bile, and black bile), and personali-

ties were manifestations of various mixtures of humors; illness resulted when

the humors, which were thought to be affected by diet, weather, and climate,

were unbalanced (Morris, 1997; Shapiro & Shapiro, 1997b; Wampold, 2001a).

The Apache shaman, elaborately dressed in animal skins and masks and whose

power derived from special status among the spirits or from possession of a

sacred object, administered rituals involving dance, drums, rattles, prayers, and

History of Medicine, Methods, and Psychotherapy 3

chants and to replace evils spirits with protective ones (Morris, 1997). Tradi-

tional Chinese medical practices, described in The I Ching (Book of Changes)

and the Huang Ti Nei Ching Su Wen (The Yellow Emperor’s Classic of Internal

Medicine), postulated five elements: water, fire, wood, metal, and earth and

combinations of the yin and yang; diseases were treated with five tastes, five

types of grain, and five flavors (e.g., pungent food was used to prevent disinte-

gration of the liver and sour food to drain the liver), supplemented by acupunc-

ture, which has persisted as a Chinese treatment for more than 2,500 years

(Shapiro & Shapiro, 1997b). Each with a medical explanation for its effect, the

pharmacopoeias of European medicine of the seventeenth century contained

such substances as Vigo’s plaster (viper’s flesh with live worms and frogs), fox

lungs, moss from the skulls of victims of violent death, Gascoigne’s powder

(bezoar, amber, pearls, crab’s eyes and claws, and coral), human urine, various

sexual organs, excreta (from many different sources), human placenta, saliva

from fasting individuals, and wood lice (Shapiro & Shapiro, 1997b).

There is no attempt to romanticize ancient or indigenous medical practices,

as it is clear that many such healing practices were ineffective and some danger-

ous (Shapiro & Shapiro, 1997a,b). Hippocrates prescribed a diet that excluded

vegetables and fruits, resulting in vitamin deficiencies. Acupuncture, due to

unsterilized needles, caused homologous serum jaundice, a deadly disease that

was prevalent in China for centuries and killed many. Dehydrating procedures,

such as bloodletting, vomiting, enemas, and leeches “killed more patients than

any other treatment in the history of medicine” (Shapiro & Shapiro, 1997a,

p. 18). Indeed, George Washington was no doubt killed by his physician, who

treated his abscessed tonsil with a variety of procedures that exacerbated the

natural dehydration of fever. Nevertheless, effective or ineffective, cultures

developed explanations for illness and developed treatments—each explanation

and the associated treatment were consistent with the beliefs and practices of

the culture and in many ways were defining features of the society.

Although the origins of Western scientific medicine can be traced to the

ancient Greeks, the preponderance of the treatments in Europe and the United

States remained ineffective, by modern standards of medicine, until at least the

nineteenth century. The introduction of the twined concepts of materialism

and specificity, arising in the Renaissance era, along with the concept of the

placebo, allowed modern medicine to ride the crest of the wave created by sci-

ence and the scientific method.

Materialism, Specificity, and the Placebo as Critical

Concepts of Modern Medicine: The Contributions of

René Descartes, Benjamin Franklin, and Louis Pasteur

Materialism, as a general philosophical term, considers matter as the sole basis

of reality and thus attempts to explain phenomena as the consequence of the

interaction of various types of matter. Applied to medicine, materialism implies

4 History of Medicine, Methods, and Psychotherapy

that any bodily state, including most importantly illness, has a physical substrate.

Specificity, which is a corollary of materialism, refers to the manner in which

treatments render their effects. A treatment is said to be a specific treatment if

the components of the treatment address illness by altering those physiochemi-

cal aspects of the body that were responsible for the illness. Generally, specificity

in medicine relies on demonstrable alterations of the physiochemical process

responsible for the disease and either a removal of the disease (i.e., cure) or a

reduction in the severity of the disorder above what could be obtained through

effects created by the mind by such factors as hope, expectation, and condition-

ing. Although materialism, as a philosophy, has been around since the ancient

Greeks, establishing specificity in medicine depended on the development of

the sciences of anatomy and physiology to explain the causes of disease and

on the development of research design and statistical methods to appropriately

test the effects of treatments.

Before Benjamin Franklin and Louis Pasteur could make their contributions

to modern medicine, a philosophical issue needed to be resolved. For most of

human history, there was no distinction between physical and mental disorders;

indeed the sciences of anatomy and physiology were not sufficient to claim

that physical disorders resided in the body and mental disorders in the mind.

The imbalances in the Pythagorean humors were sufficient to explain physi-

cal and mental disorders and there was no corroboration or refutation of the

conjecture relative to these disorders possible. (Of course, the idea of refutation

of hypotheses empirically was not yet developed, so it wasn’t simply a lack of

knowledge of anatomy and physiology.) If medicine were to find the material

bases of disorders, it would be in the arena of physical disorders and the dis-

tinction between physical and mental disorders was consequently necessary. It

was René Descartes, in the early seventeenth century, who made the distinction

between mind and body, although it was not his purpose to be at the service of

the development of medicine, as he was interested in the mind in an ontologi-

cal sense. Nevertheless, the distinction placed anatomy and physiology, which

were now subject to observation, on an empirical track; the mind remained in

the metaphysical realm and, in a manner of speaking, became the province of

psychology. Of course, as a note, there is much interest in the past few decades

on the interaction of mind and body, and advances in the neurosciences are

eliminating, according to some perspectives, the notion of the mind as distinct

from the body—rather the mind is what the brain does (Miller, 1996).

As science and the scientific method were evolving in Europe in the Carte-

sian context, it became apparent that most of the substances in the pharma-

copoeias were not effective. Indeed, only a very few seemed to be effective for

particular diseases (e.g., foxglove for congestive heart conditions and cinchona

bark for malaria) (Shapiro & Shapiro, 1997b). In 1785 the term placebo entered

the medical lexicon and was applied to treatments that were known to be inef-

fective physiochemically but satisfied the patient’s desire to be treated (Shapiro

& Shapiro, 1997b). The term, according to Walach (2003), originated from

History of Medicine, Methods, and Psychotherapy 5

the Latin psalm verse, “Placebo Domino in regione vivorum” (“I shall please

the Lord in the land of the living”), which was sung in the Middle Ages as a

prayer at the deathbed. Because others were often paid to do the singing, the

term placebo became associated with a “nearly fraudulent replacement of the

real” (Walach, 2003, p. 178). As will become apparent in subsequent discus-

sions, placebo and the effects that are derived from them are deeply imbedded

in several controversies in medicine and in psychotherapy; from the perspective

of this volume, an understanding of the placebo effect is critical to an under-

standing of psychotherapy. Nevertheless, the term placebo, from its origin, has

retained a tainted connotation—administration of a substance simply to please

the patient became repugnant and claims that a “placebo” was curative would

risk being labeled a charlatan, as Franz Anton Mesmer was soon to find out.

Contemporaneous to the development of the notion of the placebo, the

Parisian physician Mesmer had a lucrative medical practice. It was populated

with the elite of Paris but was also controversial. In his dissertation, Mesmer

(1766/1980) claimed that some illnesses were caused by the blockage of the

normal flow of an invisible universal fluid, which he called animal magnetism.

The physician could restore health by removing the blocks, and after further

“research,” Mesmer found that he could “magnetize” objects with animal

magnetism and these could be used to cure his clients (Buranelli, 1975; Gallo &

Finger, 2000; Gauld, 1992; Pattie, 1994). The success of this treatment was well

documented and led to its immense popularity in the late eighteenth century.

Mesmer, already caught up in several controversies, came under intense

scrutiny. Medicine, wanting to disavow practices that were unscientific, found

Mesmer’s cures uncomfortable. Responding to these forces, King Louis XVI of

France established in 1784 a Royal Commission, chaired by Benjamin Frank-

lin, to investigate mesmerism (Gould, 1991). Some of the experiments designed

by the commission involved patients being split into two groups, with one group

coming into contact with “magnetized” objects and the other group coming

into contact with what they believed were “magnetized” objects (i.e., according

to modern terminology, a placebo). Care was taken to ensure that the patients

did not know whether they were receiving a magnetized object or not, creating

one of the first, if the not the first, rigorous blinding in a study (here, a single

blind). This design enabled the Royal Commission to demonstrate, as there

were no differences in the cures produced by the two groups, that Mesmer’s

cures did not occur through treatment-specific ingredients.

The noted natural historian Stephen Jay Gould (1989) heralded the testing

and discrediting of Mesmer as one of the earliest and exemplary demonstra-

tions of the use of the scientific method to expose pseudoscience and charla-

tanism. However, imbedded in the Mesmer story are two points that should

not be lost in this progressive story. First, Mesmer’s treatments were effective,

as noted by the Royal Commission—benefits to patients were observable. Sec-

ond, Mesmer’s theories of illness and treatment were grounded in the best

science available, namely the theories proposed by Sir Isaac Newton, who only

6 History of Medicine, Methods, and Psychotherapy

a century earlier had crossed the threshold from a fascination with the occult

to the origins of mechanics and the advancement of mathematics (Gleick,

2003). Thus Mesmer was discredited not based on treatment effectiveness or

theoretical cogency but on the observation that the proposed mechanism of

illness remediation was questionable. This is a standard that mental health

treatments, pharmacological as well as psychological, will have, as we will see,

a difficult time satisfying. Of course, Mesmer’s exposure as a charlatan was a

conspicuous event that furthered medicine as a profession.

The third seminal person in the development of modern medicine was

Louis Pasteur, the father of germ theory (actually, paternity questions could

be raised by Robert Koch, who has a legitimate claim of fatherhood). Pasteur

exhibited the optimal blend of theory and experiment to, as the philosopher

Ernest Renan noted, “interrogate nature” until certain proofs of conjectures

were accomplished. The unifying theme, if one could characterize discoveries

across a vast array of areas as a theme, of his work is that Pasteur was able to

make inferences about the existence and characteristics of entities too small to

be observed directly. The story of how he made fermentation alive provides an

important anecdote about the inevitable interactions between epistemological

and ontological contributions (Latour, 1999).

In the 1850s, chemistry, having thrown off the vestiges of alchemy and find-

ing itself the preeminent field of science, sought chemical explanations for

most natural phenomena, including biological processes. The canonical view

at the time was that fermentation was the decay of sugars into alcohol by a

catalytic but unobserved “disintegrating disturbance,” which could be trans-

ferred from one batch of fermenting solution to another. Unfortunately for

alcohol producers, the process was unreliable and the chemical explanation

provided had little pragmatic value. Based on his prior work in crystallography

of organic substances, keen observation, and systematic experimentation, Pas-

teur hypothesized that living microorganisms were responsible for fermenta-

tion, rather than being created spontaneously as a result of the process. This

discovery led to other conclusions, including the conjecture that disease was

caused by microorganisms, which constituted the origins of the germ theory of

disease. The pairing of theory and experimentation resulted in medical prac-

tices with demonstrable benefits—vaccines using compromised organisms,

sterilization of medical environments, and sterilization of foods by heat (i.e.,

“pasteurization”).

Two aspects of the Pasteur story are critical, one quite obvious in retro-

spect and the other illustrative of more subtle implications for the philosophy

of science. Materialism applied to medicine requires physical explanations

for illness—the germ theory was exactly “what the doctor ordered.” Not only

could disease be cured or prevented, but the underlying mechanism could be

explicated in a demonstrable manner. To be sure, there was no lack of hypoth-

esized mechanisms prior to Pasteur. It was his beautifully constructed and in

the end inconvertible demonstration of how microorganisms caused disease

History of Medicine, Methods, and Psychotherapy 7

and the developments that followed as a result that changed the status of the

explanations.

From today’s perspective, the ontological nature of disease was clearly advanced

as a result of Pasteur’s work on fermentation and the idea of spontaneous gen-

eration seems absurd (see Latour, 1999), which brings us to the second point

relative to Pasteur. In 1864 the epistemological battle was just beginning to be

fought. At the time chemical decomposition was accepted as the explanation for

fermentation; the microbes observed were due to spontaneous generation as a

result rather than the cause of fermentation. Proponents of a microorganismic

explanation for fermentation, and there were some, were considered lunatics,

in the way we now think of Mesmer. The organisms were there, in retrospect,

and not there, in a contemporaneous way. In the 1860s, the disintegrating distur-

bance that catalyzed fermentation and the microbes that caused fermentation

both were unobservable. Pasteur not only ingeniously designed the experiments

so that the organisms could make themselves known and constructed the theory

to provide the cogency of the experimental results, but he rhetorically, in papers

and presentations, convinced the scientific world of the merit of his explana-

tion—the latter as difficult as the former. In a sense, Pasteur and the microor-

ganisms conspired together; neither one alone could have spawned the germ

explanation of disease (Latour, 1999).

What constitutes knowledge in a given field depends, in part, on the people

who conduct the research, create the theories, and influence the scientific com-

munity, particularly in the social sciences. Knowledge at any given time, as we

will argue in this volume, is tenuous—the nature of psychotherapy makes itself

known in response to our inquiries, but the nature of those inquiries shapes

what we accept as knowledge. We, as researchers, clinicians, and policymakers,

influence what is said to be knowledge. Descartes, Franklin, and Pasteur played

critical roles in developing, along with others in this the critical period of the

nineteenth century, the components that were necessary to form the model of

modern medicine.

The Medical Model

The Medical Model, undergirded by materialism and specificity and existing

within anatomy, physiology, microbiology, and other biological sciences, is, for

our purposes, composed of five components.

Illness or Disease

The first component is an illness or disease. The patient reports to the physi-

cian with signs and symptoms, which, along with the history, examination, and

laboratory tests, leads to a determination first whether the patient’s condition

is abnormal (i.e., deviates from what is considered normal human biological

functioning) and second, if abnormality exists, a diagnosis. Some interventions

8 History of Medicine, Methods, and Psychotherapy

are designed to prevent illness (e.g., vaccines); such preventative interventions

generally conform to the Medical Model as well.

Biological Explanation

The second component, emanating from the materialistic stance of medicine,

is that there is a biological explanation for the illness or disorder. For instance,

influenza is caused by a virus, which invades cells in the nose, throat, and lungs

of humans, where it replicates and mutates. Of course, the explanation progres-

sively becomes more sophisticated as science illuminates the process. Not infre-

quently, an explanation will turn out to be false and will be supplanted with a

better alternative, as was the progression of the explanation of peptic ulcers from

excess acid due to stress or spicy diet to the presence of the bacterium H. pylori.

Of course, the materialistic stance of medicine dictates that the explanation be

biological—something related to the anatomy or physiology of the body.

Mechanism of Change

The third component of the Medical Model is that the basis for treatment be

established at the level of the biological system causing the disease and a con-

jecture about how changing an aspect of the system will eliminate the disease

or mitigate the severity or duration of the illness. When the cause of pep-

tic ulcers was thought to be acids produced by the stomach due to stress or

diet, the mechanism of change involved neutralizing acids and changing diets,

whereas if an H. pylori infection were verified, the mechanism of change would

involve reducing the population of the bacteria with antibiotics.

Therapeutic Procedures

The presence of an explanation and the mechanism of change lead logically

to the design of a treatment, containing therapeutic procedures, which might

involve administration of a substance (i.e., a drug) or implementation of a proce-

dure (e.g., surgery). The explanation of excess acid due to stress (the explanation)

and the goal to reduce acid (mechanism of change) would suggest the adminis-

tration of a substance known to neutralize acid (i.e., an alkaline substance, such

as an antacid containing calcium carbonate). If an infection of H. pylori is veri-

fied, then the therapeutic ingredient would be an antibiotic. Medical treatments

generally require that the therapeutic procedures be consistent with the explana-

tion for the illness, disease, or disorder and the mechanism of change.

Specificity

Mesmer’s treatments based on animal magnetism conformed to the first four

components of the Medical Model: patients presented with signs and symptoms

History of Medicine, Methods, and Psychotherapy 9

of illness, there was a biological explanation for the disorder, a hypothesized

mechanism of change existed, and a particular therapeutic procedure was

followed. Mesmer’s treatment, however, failed the specificity test. Specific-

ity in the context of medicine, as already discussed, implies that the compo-

nents of the treatment are remedial through alterations of physiochemical

aspects of the body that were responsible for the illness. Antibiotics for peptic

ulcers are specific to the degree to which they work by killing the bacteria rather

than through other means, including but not limited to hope, expectation, or

conditioning. Mesmer’s cures were not specific because animal magnetism was

shown not to be responsible for the benefits of his treatments.

In medicine, specificity is established in two primary ways. First, the treat-

ment can be shown to be more effective than a placebo treatment, thus ruling

out incidental causes related to the context of the treatment. For example, with

adequate controls, if a pill is superior to a placebo, then presumably it is for

reasons unrelated to whether the patient expects the pill to be effective or is

conditioned to respond to pills in general (e.g., see Hentschel, Brandstätter,

Dragosics, Hirschl, Nemec, et al., 1993). The development of the randomized

placebo control group will be reviewed and the logic of the design discussed in

the following section.

The second means to establish specificity is to establish that the medical

treatment operates through its intended mechanism. Administration of antibi-

otics leads to a decrease in H. Pylori, which subsequently leads to healing of the

ulcer, lending support for the explanation and the mechanism of change and

thus lending support for specificity—the antibiotic works through the intended

mechanism (see Hentschel et al., 1993). Indeed, much of Pasteur’s research

was focused on explanation, mechanism, and specificity. Studies of the mecha-

nisms of disease and the effects of treatment on the intervening biological sys-

tems often precede the clinical trials that are used to establish efficacy. There

are, however, salient instances in which a drug is known to be effective but for

unknown reasons. Acetylsalicylic acid (commonly known as aspirin) was used as

an analgesic, anti-inflammatory, and antipyretic (fever reducer) before its bio-

logical mechanisms were understood.

Adaptation of the Medical Model to psychotherapy is a controversial proj-

ect, which in many ways is the subject of this volume. As we will see, the devel-

opment of psychotherapy as a treatment for mental disorders is entwined with

the development of medicine. Medicine, of course, is the predominant force

and psychotherapy is subordinate.

Evidence-Based Medicine

The development of the Medical Model and the genesis of “modern medi-

cine” without much argument resulted in positive health outcomes, including

cures of many diseases and prevention of others. To wit, small pox has been

eradicated, poliomyelitis is prevented by vaccine, deaths due to post-surgical

10 History of Medicine, Methods, and Psychotherapy

infection are rare, and antibiotics are able to treat most bacterial infections.

Nevertheless, materialism and specificity as the ontological bases of medicine

and the progress made by discrediting charlatans and creating a laboratory

science of microbiology did not directly translate into implementation of treat-

ments that resulted in optimal outcomes for patients. One hundred twenty-five

years after Mesmer’s treatments were subjected to examination and more than

50 years after Pasteur debunked spontaneous generation and established the

germ theory of disease, medicine clung to many “primitive” practices. Prior to

the First World War and the influenza epidemic of 1918, the typical medical

school in the United States was unaffiliated with a college or university, was

staffed by part-time faculty whose salaries were paid directly from student fees,

was populated by students who had not taken any science courses, let alone

attended college, and depended on a curriculum in which students never exam-

ined or treated patients and infrequently used laboratory equipment (Barry,

2004). In 1910, the Flexner report changed the nature of medical education in

the United States and Canada, and in a relatively short period of time medical

education became rigorous, competitive, and scientific. Nevertheless, little was

known about the efficacy of many medications and procedures—indeed, it

was not until the 1950s that the randomized placebo control group design was

developed, and it was not until 1980 that the Food and Drug Administration

(FDA) required such designs be used to approve drugs in the United States, as

discussed in the next section.

Numerous examples can be found to document how medical practice has

ignored accumulating evidence. For our purposes, the case of streptokinase,

an enzyme that dissolves clots, as a treatment for acute myocardial infarction is

illustrative (Hunt, 1997). Clinical trials of streptokinase began as early as 1959,

but the results, due to small sample sizes, were inconclusive, as some found a

significantly better outcome than the placebo control group while others did

not. However, as early as 1969 there was sufficient evidence, had the trials been

meta-analyzed, to conclude that this intervention was effective. Iain Chalmers,

an early advocate of meta-analyses as a means to make conclusions that could

be translated into medical practice, made the following observation:

Streptokinase was the classic example. The meta-analyses showed clearly

that the effect on mortality was statistically significant, but the experts in

cardiology and the textbook authors whose opinions dominated the field

weren’t even beginning to recommend it until the late 1980s, and then

only little by little.

(quoted in Hunt, 1997, p. 87)

From the time the evidence was persuasive to the time streptokinase was

accepted as standard practice following FDA approval in 1987, it is esti-

mated that tens of thousands of patients died because they were not admin-

istered streptokinase.

History of Medicine, Methods, and Psychotherapy 11

The streptokinase example is one of many that led to the initiation of a

movement to ensure that research evidence was translated into practice. This

movement, called evidence-based medicine, initiated in the United Kingdom and

Canada, emphasizes systematic and analytic reviews of evidence and the use

of that evidence by clinicians. In 2001, the Institute of Medicine in the United

States adopted the following definition, following closely from Sackett, Straus,

Richardson, Rosenberg, and Haynes (2000): “Evidence-based practice is the

integration of best research evidence with clinical expertise and patient val-

ues” (p. 147). This definition has been described as a “three legged stool,” in

that the use of evidence (first leg) is to be balanced with the expertise of the

clinician (second leg) and characteristics and context of the patient (third leg).

Nevertheless, an examination of the seminal book on evidence-based medi-

cine, Evidence-based Medicine: How to Practice and Teach EBM (Sackett et al., 2000)

reveals that the focus is on evidence related to the quality of diagnostic tests and

effectiveness of treatments.

Intimately tied to the evolution of modern medicine is the development

of methods that could establish specificity, most importantly the randomized

double-blind placebo control group design. Consequently, our story now turns

to the history of this design.

Randomized Designs as the “Gold Standard”

Randomized designs were needed by medicine to discriminate effects due to

the purported active ingredients from those due to the “mind,” such as hope,

expectation, and relationship with the administrator of the substance or pro-

cedure. What is now known as the double-blind randomized placebo control

group design, which is the “gold standard” for FDA approval of drugs, is a rela-

tively recent invention. The history of the development of this design is critical

to understanding the current status of psychotherapy as well as medicine and

will reveal some important aspects of the therapeutic process that were omitted.

The Development of Randomization and

Comparison Designs

Three strands, according to Danziger (1990), were intertwined to develop

the notion of control group designs. The first strand emanated from Wilhelm

Wundt, who established experimentation in psychology. In Wundt’s laboratory,

he and his students were observers, as they conceived of themselves as trained sci-

entists who could report on and interpret aspects of the mind, much in the way

that a physicist would interpret the photographic trace of a particle in a cloud

chamber. Wundt and the students would design experimental protocols and

manipulate various stimuli to record the effects, which were based on reports

of internal perception (i.e., one type of introspection). The stimulus/response

contiguity was the predominant model in experimental physiology at the time.

12 History of Medicine, Methods, and Psychotherapy

The responses reported by the Wundt’s observers were typically “judgments

of size, intensity, and duration of physical stimuli, supplemented at times by

judgments of their simultaneity and succession” (Danziger, 1990, p. 35) and

were used to derive general laws, mainly of sensation and perception.

At around the time of Wundt’s laboratory experiments, the notion of “sub-

jecting” lay individuals to various conditions can be traced to experimental

studies of hypnosis in France and constitutes the second strand. These studies

differed in an important way from Wundt’s—the French scientists were the

experimenters and the patients were subjects, a clear departure from the Wun-

dtian tradition in which the scientists were subjected to experiments and also

were observers (and authors of the research reports). That is, in the French

context the role of the experimenter (the observer) and the role of the subject

were separated. The change in role allowed the observation of classes of sub-

jects who were not able to report internal states (e.g., children) and/or whose

reports were suspect (e.g., people with mental illnesses). The paradigm, largely

steeped in the French medical context, inevitably evolved into clinical research

in that “healthy subjects” were compared to abnormal subjects with the goal

of discovering essential differences between the two classes (Danziger, 1990).

Nevertheless, in these experiments, the experimenter, a physician, had a profes-

sional relationship with the patients. It should be noted, for historical accuracy,

sporadic examples of comparisons of various samples existed before the French

physician studies (e.g., James Lind’s experiments with scurvy in the eighteenth

century), but the idea of “subjecting” participants to treatments appears to be

derived from this French tradition.

The third strand involved “applicants,” rather than observers or subjects,

and the “applicants” were not abnormal, at least at the origin of this strand.

The applicants were volunteers who paid to have their “mental faculties” tested

by Francis Galton in England, many at the International Health Exhibition

in London in 1884. During this period, phrenology was widely accepted as

a means of assessing mental abilities and there was keen interest in knowing

where one stood in relation to others. To accomplish such comparisons, Galton

and other British social statisticians, such as Karl Pearson, needed to quantify

mental ability and to locate that quantity in a distribution of scores—the impor-

tant determination was how one’s score deviated from the average (Danziger,

1990; Desrosières, 1998). In this approach, the relationship between investiga-

tor and subject was minimal: “For the Galtonian investigator the individual sub-

ject was ultimately ‘a statistic’” (Danziger, 1990, p. 58). The British statistical

approach contributed the critical concepts of measurement of unobservable

characteristics (in this case, mental abilities) and statistical distributions of such

characteristics, critical components of analysis of the observation in random-

ized control group designs. These contributions were made in the context that

led to what was considered normal or above average mental abilities and thus

logically to a class of people who were mentally defective (i.e., those who were

not normal or above average). Unfortunately, this led as well to calibration of

History of Medicine, Methods, and Psychotherapy 13

“genetic worth,” which using the principles of Charles Darwin’s (Galton’s cousin)

theory of evolution, spawned the field of eugenics (see Desrosières, 1998).

Wundt introduced laboratory methods in psychology and attempted to

extract general rules. The French researchers devised designs in which the

experimenter subjected research participants to various conditions and com-

pared abnormal to normal persons. The British social statisticians provided

the statistical theory related to deviations from the mean. These were all criti-

cal components of clinical trials in medicine and psychotherapy, but the miss-

ing component to this mix was randomization. The impetus for that critical

component came, in part, from the desire to provide pragmatic knowledge

to various consumer groups. Academic psychologists deemed education an

apt context to demonstrate the utility of their nascent discipline. In the early

1920s, the treatment group methodology was “being sold to American school

superintendents as the ‘control experiment’ and touted as a key element in

comparing the ‘efficiency’ of various administrative measures” (Danziger,

1990, p. 114). Shortly thereafter, McCall (1923) published How to Experiment

in Education, which introduced control group experimentation in education

and discussed the notion of randomization. At about the same time, Sir Ron-

ald Fisher took a position at an agricultural station where he developed the

analysis of variance and various other procedures for comparing crop yields

(Gehan & Lemak, 1994). Fisher’s work in randomized experimental designs

and the analysis of data derived from such designs was absolutely stunning—

arguably the design and analysis of every clinical trial in medicine, psychol-

ogy, and education is based on methods developed by Fisher (Danziger, 1990;

Shapiro & Shapiro, 1997b) or derived from his work. Fisher’s publications,

most prominently The Design of Experiments, which appeared in 1935, became

particularly useful to medical researchers eager to show the efficacy of various

medications, although one additional component, the placebo control, was

needed (Gehan & Lemak, 1994).

Introduction of Placebo Controls to Rule

Out Nuisance Variables

The goal of modern medicine was to establish that the benefits of any medical

treatment were due to the physiochemical properties of the medication and not

to the patient’s expectations, hopes, or other psychological processes, thereby

establishing the specificity of the purported active ingredients of the medica-

tion. To rule out threats due to these psychological factors, researchers in the

late 1930s began to use double-blind placebo studies in the United States and

the United Kingdom, but the method did not take root, apparently because

placebo carried a negative connotation (Gehan & Lemak, 1994; Shapiro &

Shapiro, 1997a, b). Gradually however, the acceptance of the randomized

double-blind placebo design spread. Harry Gold, a pharmacologist and one of

those given credit for the development of the placebo control group design in

14 History of Medicine, Methods, and Psychotherapy

the United States, participated in several conferences at Cornell University on

the subject in the late 1940s and early 1950s; he became the first professor of

clinical pharmacology, a new discipline. As noted by Shapiro and Shapiro (1997b):

Gold advocated a comparison between “an allegedly potent agent and a

blank of such physical properties as to render a distinction between the

two impossible except through some pharmacologic potency which may

exist. . . . [the recommended] double-blind procedure which calls for an

investigation in which neither the patient nor the doctor is aware of the

identify of the two agents until the results are in and analyzed. This is

imperative to avoid the influence of subconscious bias . . .” (Gold, 1954,

p. 724). The statement by Gold culminated twenty years of pioneering

study of methods with which to reliably and validly evaluate the effective-

ness of new drugs.

(p. 148)

By 1980, the FDA required that evidence for the effectiveness of a drug be

obtained from randomized double-blind placebo trials—historically speaking,

a relatively recent development (see Figure 1.1 ).

The importance of the randomized double-blind placebo control group

design methodologically and conceptually should not be underestimated. It

took more than 300 years from Descartes’ dualism of mind and body and

nearly 200 years from the time that Mesmer was discredited on specificity

claims to the institutionalization of a design that could rule out psychological

threats to the establishment of the specific effects of substances on the body

(see Figure 1.1 ).

Before leaving the short history of experimental designs, it is worth reiterat-

ing that there are two critical features of the randomized double-blind placebo

control group design. The first is that the placebo administered as a control

for psychological factors should be indistinguishable from the treatment in all

respects. For trials of medications, the pharmaceutical industry manufactures

placebos that are identical to the purportedly active medications in taste, shape,

color, and form. One of the problems, as will be discussed in later chapters, is

that subjects will try to guess which condition they are in and will use any cues

available (e.g., the presence or absence of side effects).

The second critical feature of the randomized double-blind placebo control

group is related to blinding. In actuality, the “double-blind” moniker refers to a

triple-blind: the administrator of the intervention, the patient, and the evalua-

tor, throughout the study, are ignorant of which treatment (medication or pla-

cebo) the patient is receiving. Any deviation from the blind could result in bias,

either directly (e.g., by an evaluator who might unconsciously score a protocol

to favor the medication) or through cues provided to the patient (e.g., greater

enthusiasm when delivering the medication than when delivering the placebo).

Issues in blinding will be discussed in subsequent chapters. 1

Figure 1.1

Timeline of important events in psychotherapy.

16 History of Medicine, Methods, and Psychotherapy

Psychotherapy emerged in the context of the development of modern medi-

cine and utilized in part the randomized design to legitimate its standing. We

now turn to the third history.

The Emergence of Psychotherapy

as a Healing Practice

The Origins of Talk Therapy in the United States

In the short history of modern medicine, little mention was made of mental

disorders. In the late nineteenth century, medicine was attempting to be seen

as a legitimate profession based on scientific principles, and as discussed previ-

ously, medicine emphasized physiochemical (i.e., somatic) processes. Medicine’s

attitude toward mental health problems was one of psychophysical parallel-

ism: mental states corresponded with physical states and it was hypothesized

that mental disorders were caused by some (unknown) physiochemical process

(Caplan, 1998). Of course, most disorders, mental or physical, at the time had

unknown causes; they were classified as functional (cause unknown) as opposed to

structural (i.e., cause known). Attempts were made to discover the physiochemical

causes of mental disorders and, for the most part, psychosocial causes and any

type of mental therapeutics (e.g., talk therapy) were assiduously avoided.

According to Caplan (1998), several events in the United States conspired

to challenge the emphasis on physiochemical explanations. First, the train as

a means of transportation emerged. Trains, of course, differed in many ways

from previous forms of transportation, but for purposes of the development of

psychotherapy, the important aspect was that trains, when things went awry,

created catastrophic collisions, which produced a multitude of various injuries.

A frequent complaint of those in the collisions involved a diffuse constella-

tion of symptoms, which usually included back pain, and led to the diagnosis

of “railway spine.” What was troubling for medicine was that witnesses on

the platforms near the collisions reported many of the same symptoms even

though they had not been involved in the physical trauma, a phenomenon that

cast doubt on a physiochemical cause of reported symptoms and introduced

the notion that the mind has a role in symptoms.

The second perspicuous precursor of psychotherapy was related to the dis-

order neurasthenia, which was characterized by fatigue, anxiety, headache,

impotence, neuralgia, and depression, and which became a prevalent disorder

in the United States. Although of unknown origin, it was hypothesized that it

was caused by a depletion of energy in the nervous system. Not surprisingly,

the treatments for neurasthenia varied dramatically, which interested some pre-

scient physicians:

How was it, certain physicians asked, that so many different modalities of

somatic therapies ranging from electricity and hydrotherapy to diet, rest,

History of Medicine, Methods, and Psychotherapy 17

nutrition, and medication could achieve identical results? Might they not

share a common ground? Deducing from the variegated experiences of a

wide array of somatic treatments, the Boston neurologist Morton Prince

declared, “I think if these treatments are carefully analyzed it will be found

that there is one factor common in them all, namely, the psychical element.”

(emphasis added, Caplan, 1998, p. 45)

Needless to say, the introduction of the psyche in medical circles was not well

received.

The third precursor to psychotherapy was development in various contexts

of “mind cures.” In the mid- to end of the nineteenth century, as medicine con-

centrated on the physiochemical, an increasing number of Americans turned

toward practices that healed through the mind, most popular of which were

Christian Science and the New Thought movement. Although these move-

ments may seem to be relics of the past or marginalized religious practices, they

were immensely popular (Caplan, 1998; Taylor, 1999). Christian Science, with

only about 9,000 members in 1890, had more than 50,000 by 1906 (Caplan),

which perhaps seems a modest number, but Christian Science was only one of

many institutions that claimed to physically heal through mind, faith, or spiri-

tuality. Cushman (1992) attributes the popularity of these movements to the

lack of a spiritual core in America and the desire to break free of the rigidity of

a Victorian society (see also Taylor, 1999).

At first, medicine deliberately dismissed these movements, for the most part,

as unscientific attempts to cure illnesses, whether physical or mental. Legiti-

macy lagged popularity, but gradually the involvement of American psycholo-

gists lent credibility to the idea of talk therapy as distinct from the religious

movements. The Boston School of Psychopathology, initiated in 1859, which

was an informal group of investigators, including the psychologists William

James and G. Stanley Hall as well as neurologists and psychiatrists, was to

become the epicenter of the new talk therapy. In 1906, the Emmanuel Move-

ment was initiated as a collaboration between physicians who recognized the

importance of the psyche and Christian ministers who recognized the moral

aspect to behavior; lectures and services were followed by the administration

of “therapy” to patients (Caplan, 1998; Taylor, 1999). The particularly threat-

ening aspect of the Emmanuel Movement for medicine was that patients were

being treated by psychical methods and often by non-physicians.

The manifestation of physical symptoms in the absence of physical cause,

the efficacy of various incompatible treatments for a prevalent disorder, and

the increasing popularity and legitimacy of talk therapies for physical and

mental disorders were problematic for the emerging modern medical profes-

sion. And thus a dilemma for medicine: reject the emerging psychotherapeu-

tics because it treated psychic disorders with non-medical means (viz., talk) or

absorb the lucrative professional practice of mental therapeutics. Interestingly,

talk therapies in America at this period had a connection with those interested

18 History of Medicine, Methods, and Psychotherapy

in Mesmer’s cures, which surely aroused the suspicions of physicians (Caplan,

1998; Cushman, 1992). Given the context, it is not surprising that medicine

resisted acknowledging mental factors in the etiology, pathology, and treatment

of mental disorders, and efforts were made to discredit mental therapeutics. On

the other hand, some psychologists, although not all by any means, were inter-

ested in such treatments and their mechanisms: “As early as 1894, [William]

James publicly assailed a proposal to proscribe the practice of mental healing,

‘What the real interest of medicine requires,’ James proclaimed, ‘is that mental

therapeutics should not be stamped out, but studied, and its laws ascertained’”

(Caplan, 1998, p. 63).

In the end, medicine could not allow patients to be treated outside of the

medical authority and it exerted its professional privilege to conduct psycho-

therapy. The sentiment was expressed by prominent physician John K. Mitch-

ell, “Most earnestly should we insist that the treatment of a patient, whether it be

surgical, medical, or psychic, should for the safety of the public, be in the hands

of a doctor” (Caplan, 1998, p. 142). What was missing was a cogent theory of

mental disorder and that would soon be provided.

Theoretical Orientations

Freud and the Origins of Psychodynamic Psychotherapy

When Sigmund Freud gave his lectures at Clark University in 1909, talk ther-

apy was established as a legitimate medical practice in the United States, but

he provided the missing theoretical coherence and all the better that it was

provided by a physician and in the medical context. Within six years, psycho-

analysis had become the predominant form of psychotherapy in the United

States: “Psychoanalysis appeared to be more proper and civilized than mind

cure, more scientific than Christian Science and positive thinking, and more

medical than advertising” (Cushman, 1992, p. 38).

Sigmund Freud, in his practice as a physician, became involved with the

treatment of hysterics. He proposed that a) hysteric symptoms were caused by

the repression of some traumatic event (real or imagined) in the unconscious;

b) the nature of the symptom was related to the event; and c) the symptom

could be relieved by insight into the relationship between the event and the

symptom. Moreover, from the beginning (as in his discussion of Anna O.), sex-

uality became central to the etiology of hysteria, with many symptoms associ-

ated with early sexual traumas. Freud experimented with various techniques

to retrieve repressed memories, including hydrotherapy, hypnosis, and direct

questioning, eventually promoting free association and dream analysis. From

these early origins of psychoanalysis, the components of the Medical Model

were apparent: a disorder (hysteria), a scientifically based explanation of the

disorder (repressed traumatic events), a mechanism of change (insight into

unconscious), and specific therapeutic actions (free association).

History of Medicine, Methods, and Psychotherapy 19

During his lifetime, Freud and his colleagues differed on various aspects

related to theory and therapeutic action, creating irreconcilable rifts with such

luminaries as Joseph Breuer, Alfred Adler, and Carl Jung, the latter two of

whom were expelled from Freud’s Vienna Psychoanalytic Society. The Medi-

cal Model is characterized by insistence on the correct explanation of a disor-

der and adoption of the concomitant therapeutic actions that are responsible

for the patient benefits. Freud insisted that his theory was correct and that his

treatments were specific and supported by scientific evidence. Although from

a current vantage point, the empirical bases of Freudian psychoanalysis and

competing systems (e.g., Adler’s individual psychology or Jung’s analytic psy-

chology) seem to be tenuous, at best, there are claims that neuroscience has

corroborated many psychodynamic constructs and theory (e.g., Westen, 1998).

Regardless of the debates about the scientific merit of psychodynamic con-

cepts, it should be realized that Freud’s complex theories were introduced prior

to Flexner’s report and the reformation of medicine that resulted; that is, the

substance and bases for Freud’s claims were suitable for the period in which

they occurred.

One critical point for our history of psychotherapy is related to the degree

to which psychotherapy for the first half of the twentieth century was the prov-

ince of medicine. As we have seen, psychotherapy was already incorporated

into medicine at the turn of the century and Freud, a physician, provided an

explanation acceptable to the medical profession. Moreover, admittance to psy-

choanalytic institutes and the practice of psychoanalysis was limited primarily

to physicians, further defining psychotherapy as a medical practice. Interest-

ingly, Freud himself trained lay (i.e., non-physician) analysts, the most notable

of whom was Theodore Reik, who was charged with the crime of practic-

ing medicine without a license. Although Reik was acquitted, upon Freud’s

death, access to the psychoanalytic institutes for non-physicians, including

psychologists, was further restricted (VandenBos, Cummings, & DeLeon,

1992). As noted by Jerome Frank (1992), until mid-century, in the research

context particularly, “The division of labor by discipline was unquestioned:

Psychologists did intelligence testing and assessment of personality, usually

the Rorschach test; social workers did the interviewing; and psychiatrists con-

ducted therapy” (p. 392).

An Alternative to Psychodynamic Approaches:

The Rise of Behaviorism

Behavioral psychology emerged as a parsimonious explanation of behavior

based on objective observations. Ivan Petrovich Pavlov’s work on classical con-

ditioning detailed, without resorting to complicated mentalistic constructs, how

animals acquired a conditioned response, how the conditioned response could

be extinguished (i.e., extinction), and how experimental neurosis could be

induced. John B. Watson and Rosalie Rayner’s “Little Albert Study” established

20 History of Medicine, Methods, and Psychotherapy

that a fear response could be conditioned by pairing a stimulus of fear (viz.,

loud noise) with a previously unconditioned stimulus (viz., a white rat that

Albert had played with without fear) so that the unconditioned stimulus (i.e.,

the rat) elicited the fear response (i.e., became a conditioned stimulus; Watson

& Rayner, 1920). Although Watson and Rayner did not attempt to alleviate

Albert’s fear, Mary Cover Jones (under the supervision of Watson) demon-

strated that the classical conditioning paradigm could be used to desensitize a

boy’s fear of rabbits by gradually increasing the proximity of the stimulus (i.e.,

the rabbit) to the boy in a pleasant state, which was established with Albert’s

favorite food.

A major impetus to behavioral therapy was provided by Joseph Wolpe’s

development of systematic desensitization. Wolpe, who like Freud was a medi-

cal doctor, became disenchanted with psychoanalysis as a method to treat

his patients. Based on the work of Pavlov, Watson, Rayner, and Jones, Wolpe

studied how eating, an incompatible response to fear, could be used to reduce

phobic reactions of cats, which he had previously conditioned. After studying

the work on progressive relaxation by physiologist Edmund Jacobson, Wolpe

recognized that the incompatibility of relaxation and anxiety could be used to

treat anxious patients. His technique, which was called systematic desensitiza-

tion, involves the creation of a hierarchy consisting of progressively anxiety-

provoking stimuli, which are then imagined by patients, under a relaxed state,

from least to most feared. His seminal book Psychotherapy by Reciprocal Inhibition,

in which he explicated how classical conditioning could be used as a psycho-

logical treatment, was published in 1958—at about the same time the medical

barrier was lowered and psychologists began to practice psychotherapy more

prevalently.

Although the explanation of anxiety offered by the psychoanalytic and clas-

sical conditioning paradigms differ dramatically, systematic desensitization has

many structural similarities to psychoanalysis. It is used to treat a disorder (pho-

bic anxiety), is based on an explanation for the disorder (classical condition-

ing), imbeds the mechanism of change within the explanation (desensitization),

and stipulates the therapeutic action necessary to effect the change (systematic

desensitization). So, although the psychoanalytic paradigm is saturated with

mentalistic constructs whereas the behavioral paradigm generally eschews

intervening mentalistic explanations, they are both systems that explain mal-

adaptive behavior and offer therapeutic protocols for reducing distress and

promoting more adaptive functioning. Proponents of one of the two systems

would claim that their explanations and protocols are superior to the other.

Indeed, Watson and Rayner (1920) were openly disdainful of any Freudian

explanation for Albert’s fears:

The Freudians twenty years from now, unless their hypotheses change,

when they come to analyze Albert’s fear of a seal skin coat—assuming

that he comes to analysis at that age—will probably tease from him the

History of Medicine, Methods, and Psychotherapy 21

recital of a dream which upon their analysis will show that Albert at three

years of age attempted to play with the pubic hair of the mother and was

scolded violently for it.

(p. 14)

The behaviorists claimed that they rejected the Medical Model. However,

it was the biological bases of mental illness that was antithetical to their theo-

retical position, as behaviorists at this period in time considered the child a

tabla rasa onto which experience writes and, therefore, problems of adult liv-

ing, including mental illness, are consequences of the learning history of the

individual. Nevertheless, the idea of treating a particular problem, say a simple

phobia, specifically with a particular treatment, say Wolpe’s systematic desensi-

tization, was critical to the behavioral paradigm.

As cognition gained a more prominent position in experimental psychol-

ogy, several psychotherapy theoreticians and researchers, some of whom

were trained as analysts or who were steeped in psychodynamic theory and

practice and others of whom came from a behavior or social learning per-

spective, developed models of cognitive therapy. It is debatable whether the

contributions of these luminaries, including Albert Ellis, Aaron Beck, Michael

Mahoney, and Donald Meichenbaum, represented a subsystem of behavior

therapy, which had become increasingly pragmatic and less tied to experimen-

tal paradigms (Fishman & Franks, 1992), or should be classified as a distinct

paradigm (Arnkoff & Glass, 1992). As we shall see, the issue of treatment

distinctiveness and evolution of treatment paradigms will reappear in several

prominent instances in this volume. For the purposes of this book, the term

cognitive-behavior therapy (CBT) will be used to refer to behavioral and cogni-

tive therapies, although in some instances CBT will be used to refer to a very

specific treatment modality. Indeed, as discussed in several places, the defini-

tion of CBT is ambiguous and there are disagreements about whether a par-

ticular treatment is or is not CBT.

Humanism as a Third Force

In the context of post–World War II modernism and attempts to make mean-

ing of life given the ravages of war and the Holocaust, psychotherapy devel-

oped a third force (after psychoanalysis and behavioral therapy) derived from

the humanistic philosophers (e.g., Kierkegaard, Husserl, and Heidegger).

Humanistic approaches have in common a) a phenomenological perspective

(i.e., therapy must involve understanding the client’s world); b) an assumption

that humans seek growth and actualization; c) a belief that humans are self-

determining; and d) a respect for every individual, regardless of their role or

actions (Rice & Greenberg, 1992). The best known of the original human-

istic therapies are person-centered therapy (Carl Rogers, as discussed e.g.,

in Client-Centered Therapy, 1951a), Gestalt Therapy (Frederick “Fritz” Perls),

22 History of Medicine, Methods, and Psychotherapy

and existential approaches (e.g., Rollo May and Victor Frankl). Humanistic

approaches emanated from distinctly non-medical origins and non-experimental

traditions, having roots more in philosophy than in science and medicine.

Status of Various Psychotherapies

Although dividing up the psychotherapy universe into three forces, psychody-

namic, cognitive-behavioral, and humanistic, is arbitrary, it is revealing to ask,

“What is the relative status of these forces?” Status, of course, is an ambiguous

term, but three sources of information relative to the question are available:

texts and other artifacts, psychotherapy practice, and research foci.

In a report on National Public Radio’s All Things Considered ( June 2, 2004) on

the treatment of a woman suffering social phobia, Alix Spiegel began by stating,

“Cognitive-behavioral therapy is the fastest growing and most rigorously stud-

ied form of psychotherapy. It is fast becoming what people in America mean

when they say they are getting therapy.” And it is not only the media that give

primacy to some treatments over others. The Oxford Textbook of Psychotherapy

(Gabbard, Beck, & Holmes, 2005), a comprehensive and voluminous treatment

of the subject, indicated that the editors “tried to ensure that the diverse psy-

chotherapeutic strategies were represented in a balanced way in each chapter,”

but the 534-page text discusses primarily cognitive-behavioral and psychody-

namic approaches—humanistic approaches and their developers were mostly

ignored (Wampold & Imel, 2006). As noted by Rice and Greenberg (1992),

“During the last two decades . . . the humanistic psychotherapy approaches

have become increasingly separated from mainstream theoretical psychology,

especially in North America” (p. 214).

The types of treatments delivered by therapists constitute another indicator of

the status of psychotherapies. Every 10 years, Norcross and colleagues survey

psychologists with regard to a number of practices, including type of treatment

provided (see Norcross & Karpiak, 2012; Norcross, Karpiak, & Santoro, 2005,

for the most recent surveys of clinical psychologists). The results of the survey

show a remarkable rise in the proportion of clinical psychologists who report

that their orientation was cognitive: in the 1960s and 1970, virtually no clinical

psychologist reported that they were cognitively oriented, whereas in the most

recent survey (viz., 2010), about one-third do so. If one combines cognitive with

behavioral, which has been steadily rising from 8 percent in 1960 to 15 percent in

2010, then 45 percent of clinical psychologists in the United States report that

their primary orientation is either cognitive or behavioral (Norcross et al., 2012).

On the other hand, the proportion that report a dynamic or eclectic/intregrative ori-

entation has decreased from 35 percent and 36 percent, respectively, in 1960 to

18 percent and 22 percent in 2010, respectively. All other orientations, includ-

ing Rogerian, humanistic, systems, and interpersonal, among others, were only

endorsed by 14 percent of the clinical psychologists responding in the 2010 sur-

vey. Of course, psychotherapy is not solely practiced by clinical psychologists,

History of Medicine, Methods, and Psychotherapy 23

but it appears, nevertheless, that not only have humanistic approaches been

abandoned (or perhaps have abandoned) mainstream theoretical psychology,

as Rice and Greenberg (1992) suggested, but psychotherapists (at least psy-

chologists) have abandoned these approaches as well.

The third source of information, which is derived from research foci, is dis-

cussed in the next section, where a history of developments in psychotherapy

research is presented. The conclusion here, however, is that cognitive behavioral

treatments clearly enjoy an elite status; however, many practicing therapists

indicate that they are delivering eclectic or integrative forms of psychotherapy.

Research Methods, Psychotherapy Efficacy, and

the Ascendancy of Treatments for Disorders

The need to demonstrate the efficacy of psychotherapy in general and vari-

ous treatments specifically shaped the development of psychotherapy. Research

methods played an important role in this development, as more advanced

methods were needed to demonstrate the effects of psychotherapy.

Research Methods Driven by a Need to

Demonstrate Efficacy

Research methods in psychotherapy have paralleled those of medicine. A clear

example is found with Freud, who considered himself a scientist but preferred

clinical findings of his treatments to results of statistical analyses of data. This

was not surprising given the state of such methods in the early twentieth cen-

tury. In the case method used by Freud, only trained psychoanalysts could be

“objective and impartial observers” to determine the outcomes of a specific

treatment. The case methods used by Freud and colleagues documented that

their treatments were remarkably successful but created much doubt by those

outside of the psychoanalytic community (Strupp & Howard, 1992). Indeed,

one of the continuing criticisms of psychoanalytic approaches has been the

lack of objective verification of outcomes.

The first direct observation of psychotherapy emanated from the humanistic

tradition, which is somewhat surprising given the phenomenological bent of

this school. While advocates of other approaches, particularly the psychoana-

lysts, were loathe to invade the sanctity of the interview room, in the 1940s

Carl Rogers and his group prepared transcripts of sessions from audio tapes,

a technology that was evolving at the time (Rice & Greenberg, 1992). From

this source material, Rogers and his research group generated hypotheses that

were to be tested by the evolving research methods being developed in educa-

tion and psychology (see, e.g., Rogers, 1951b). Rogers as well as researchers

at the Menninger Foundation and the University of Pennsylvania examined

whether psychotherapy resulted in changes in personality. Generally samples

were small, treatments were not well defined, disorders were not assessed and

24 History of Medicine, Methods, and Psychotherapy

codified, and outcomes were not well specified or operationalized (Goldfried &

Wolfe, 1996; Strupp & Howard, 1992).

Not long after Rogers first began his program of research, Hans Eysenck

published a series of articles and books (Eysenck, 1952, 1961, 1966) in which

he claimed that the rate of recovery of patients receiving psychotherapy was

equal to the rate of spontaneous remission, a damning indictment of the effects

of psychotherapy. The issue of psychotherapy effectiveness will be presented in

Chapter 4 , including an elaboration of the history related to the issue. It should

be noted here, however, that the term “psychotherapy” was used by Eysenck to

refer to psychodynamic, humanistic, and eclectic treatments; behavior therapy

in his view was distinct from these treatments as it was based on learning theory

(i.e., scientific principles). In Eysenck’s view, behavior therapy should be pre-

ferred to the alternatives treatments (see Wampold, 2013).

Eysenck’s claims generated much debate (see Chapter 4 ) and also instigated

increased rigor relative to the research designs employed to test the effects of

various psychotherapies (Wampold, 2013). The randomized design, developed

in the 1920s and 1930s, as well as the placebo control group design, devel-

oped in the 1950s, offered psychotherapy researchers designs that had the

potential to answer the question of whether psychotherapy was effective. In

1956, Rosenthal and Frank recommended the use of placebo-type controls in

psychotherapy research in order to establish the specificity as well as efficacy

of psychotherapy:

It may be possible to study the possible specific effects of any particular

form of therapy by the use of a matched control group participating in an

activity regarded therapeutically inert from the stand point of the theory

of the therapy being studied. That is, it would not be expected to produce

the effects predicted by the theory. The “placebo psychotherapy” in a sense

would be analogous to placebos in that it would be administered under

circumstances and by persons such that the patients would be expected to

be helped by it.

(pp. 299–300)

Although the use of placebo control groups in psychotherapy research is

problematic (see Chapter 8 ), historically Rosenthal and Frank’s recommenda-

tion was emblematic of psychotherapy’s close connection with medicine. Psy-

chotherapy was adopting models of research that were used by medicine to

demonstrate the effects of medications, thereby conceptualizing psychotherapy

as a medical treatment. This is a trend that has increased over the decades such

that beginning in the 1980s psychotherapy began to label its outcome research

as clinical trials as it sought to establish the viability of particular treatments for

particular disorders. The use of placebo-type control groups in psychotherapy

research was an attempt to show that psychotherapies, like drugs, were spe-

cific, which as we have seen, is a distinguishing feature of modern medicine.

History of Medicine, Methods, and Psychotherapy 25

Purportedly, the superiority of a particular psychotherapy to a placebo estab-

lishes the specificity of the treatment but also established the legitimacy of the

psychotherapy enterprise.

The next important development in psychotherapy research turns the tables,

as it originates in psychotherapy research (as well as in education) and was

“exported” to medicine. As will be seen more fully in Chapter 4 , one of the

issues that emanated from Eysenck’s claims was how the results of multiple

studies should be aggregated, as the conclusions were closely tied to the method,

particularly the manner in which studies were included and excluded and how

the results of the included studies were synthesized. Mary Lee Smith and Gene

Glass, in 1977, published a meta-analysis of all studies that compared a psy-

chotherapeutic approach to some type of control group, thereby demonstrat-

ing the utility of the method of meta-analysis, which will be described more

completely in Chapter 3 . Subsequently, meta-analysis has become the standard

method of aggregating research results in education, psychology, and medi-

cine. Importantly for psychotherapy, Smith and Glass (1977; Smith, Glass, &

Miller, 1980) found that psychotherapy was indeed efficacious, a conclusion

that will be examined fully in Chapter 4 .

An issue addressed by Smith and Glass, but one that was not resolved, was

so indigenous to modern medicine that it does not get addressed explicitly.

No one asks, “Does medicine work?” but rather, “Which treatment works best

for this particular disorder?” Post Smith and Glass, psychotherapy turned, à

la medicine, to identifying particular treatments that were effective for treat-

ing particular disorders (see Chapter 5 ). To address this issue, first treatments

were to be standardized, accomplished with treatment manuals, after which the

standardized treatments could be tested and compared.

Psychotherapy Treatment Manuals

A treatment manual contains “a definitive description of the principles and

techniques of [the] psychotherapy . . . [and] a clear statement of the operations

the therapist is supposed to perform (presenting each technique as concretely

as possible, as well as providing examples of each)” (Kiesler, 1994, p. 145).

The purpose of the treatment manual is to create standardization of treat-

ments, thereby reducing variability in the independent variable in clinical tri-

als, and to ensure that therapists deliver correctly the specific ingredients that

are characteristic of the theoretical approach. With regard to the latter point,

manuals enable “researchers to demonstrate the theoretically required pro-

cedural differences between alternative treatments in comparative outcome

studies” (Wilson, 1996, p. 295). Credit for the first treatment manual usually is

attributed to Beck, Rush, Shaw, and Emery (1979), who delineated cognitive-

behavioral treatment for depression. The proliferation of treatment manuals

since the Beck et al. manual in 1979 has been described as a “small revolu-

tion” (Luborsky & DeRubeis, 1984). Treatment manuals have become required

26 History of Medicine, Methods, and Psychotherapy

for the funding and publication of outcomes research in psychotherapy: “The

treatment manual requirement, imposed as a routine design demand, chis-

eled permanently into the edifice of psychotherapy efficacy research the basic

canon of standardization” (Kiesler, 1994, p. 145).

The treatment manual, as a research operation, is imbedded in the Medical

Model. The typical components of the manual, which include defining the tar-

get disorder, problem, or complaint; providing a theoretical basis for the disorder,

problem, or complaint; as well as the change mechanism; specifying the thera-

peutic actions that are consistent with the theory; and the belief that the specific

ingredients lead to efficacy, are identical to the components of the Medical Model.

Empirically Supported Treatments

The second development in psychotherapy research related to the issue of

treatments and disorders was the idea of “empirically supported treatments”

(ESTs). The emphasis in the 1990s on managed care in medicine and related

health areas, including mental health, created the need to standardize treat-

ments and provide evidence of efficacy. As diagnosis-related groups (DRGs),

which allowed fixed payment per diagnosis, became accepted in the medical

community, psychiatry responded with psychopharmacological treatments (i.e.,

drugs) for many mental disorders; the Medical Model in medicine was making

significant inroads in the treatment of mental disorders. A task force of Divi-

sion 12 (Clinical Psychology) of the American Psychological Association (APA)

reacted in a predictable way: “If clinical psychology is to survive in this heyday

of biological psychiatry, APA must act to emphasize the strength of what we

have to offer—a variety of psychotherapies of proven efficacy” (Task Force on

Promotion and Dissemination of Psychological Procedures, 1995, p. 3). Accord-

ingly, to identify treatments that would meet the criteria of being empirically

validated (the term originally used), the task force developed criteria, which if

satisfied by a treatment, would result in the treatment being included on a list

published by the task force. Although the criteria have evolved, they originated

from the criteria used by the FDA to approve drugs. The criteria essentially

stipulated that a treatment would be designated as empirically validated for

a particular disorder provided that at least two studies showed superiority to

groups that attempted to control for general effects and were administered to a

well-defined population of clients (including importantly the clients’ disorder,

problem, or complaint) using a treatment manual.

The first attempt to identify treatments that satisfied the criteria netted 18

well-established treatments (Task Force on Promotion and Dissemination of

Psychological Procedures, 1995). Revisions to the list were made subsequently

(Chambless et al., 1996; 1998) and included such treatments as cognitive behav-

ior therapy for panic disorder, exposure treatment for agoraphobia, behavior

therapy for depression, cognitive therapy for depression, interpersonal therapy

for depression, multicomponent cognitive-behavioral therapy for pain associated

History of Medicine, Methods, and Psychotherapy 27

with rheumatic disease, and behavioral marital therapy for marital discord. A

special issue of the Journal of Consulting and Clinical Psychology was devoted to a dis-

cussion of ESTs and the identification of empirically supported treatments for

adult mental disorders, child and adolescent disorders, health related disorders

(viz., smoking, chronic pain, cancer, and bulimia nervosa), and marital distress

(Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998; Beutler, 1998; Borkovec

& Castonguay, 1998; Calhoun, Moras, Pilkonis, & Rehm, 1998; Chambless &

Hollon, 1998; Compas, Haaga, Keefe, Leitenberg, & Williams, 1998; Davison,

1998; DeRubeis & Crits-Christoph, 1998; Garfield, 1998; Kazdin & Weisz,

1998; Kendall, 1998).

With ESTs, psychotherapy had taken another step toward adopting the

Medical Model. First, the criteria clearly orient psychotherapy to disorder,

problem, or complaint: “We do not ask whether a treatment is efficacious; rather,

we ask whether it is efficacious for a specific problem” (Chambless & Hollon,

1998, p. 9). Although use of the Diagnostic and Statistical Manual (DSM) as the

nosology for assigning disorders was not mandated, Chambless and Hollon

indicated the DSM has “a number of benefits” for determining ESTs; indeed

those who have reviewed research in order to identify ESTs typically use the

DSM to organize the review (e.g., DeRubeis & Crits-Christoph, 1998).

The requirement that only treatments administered with a manual are

certifiable as an EST further demonstrates a connection between ESTs and

the Medical Model because, as discussed above, manuals are intimately tied

to the Medical Model. The lists of empirically supported treatments were

dominated by behavioral and cognitive-behavioral treatments, with a few

exemplars of psychodynamic-derived treatments and no humanistic treat-

ments, which may reflect the fact that behavioral and cognitive-behavioral

treatments are easier to manualize than are humanistic or psychodynamic

treatments and fit more neatly into the clinical trial paradigm.

A third perspicuous aspect of the EST movement is the criteria, which were

patterned after the FDA drug-approval criteria that require that evidence is

needed relative to specificity as well as efficacy. According to the EST criteria,

specificity is established by demonstrating superiority to pill or psychological

placebo or by showing equivalence to an already-established treatment. Clearly,

specificity, a critical component in the Medical Model of psychotherapy, under-

girds the EST movement. 2 Indeed, the motivation to adopt a Medical Model

in order to bolster the status of psychotherapy was evident from the beginning:

We [The Task Force] believe establishing efficacy in contrast to a waiting

list control group is not sufficient. Relying on such evidence would leave

psychologists at a serious disadvantage vis-a-vis psychiatrists who can point

to numerous double-blind placebo trials to support the validity of their

interventions.

(Task Force on Promotion and Dissemination

of Psychological Procedures, 1995, p. 5)

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