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Dare to go deep

by Jonathan Shedler, PhD

One might assume from such comments that there is strong scientific
evidence that evidence-based (read "manualized") therapy is superior to
psychotherapy as practiced by most clinicians in the real world.
Does scientific evidence really show this?
Myth #1: Evidence-based therapy is more effective than other
The lions share of research supporting evidence-based therapy comes
from studies that compare evidence-based therapy to no therapy, or to
control groups that receive sham-therapies that serve as foils and are not
designed to be seriously competitive alternatives. Sham-therapy control
conditions are often labeled Treatment As Usual but are anything but.
Patients in the control groups rarely receive any form of legitimate
This research tells us only that evidence-based therapy is more helpful
than doing nothing (or doing something that is not meant to be a serious
alternative). It tells us nothing about how "evidence based" therapy stacks
up against real-world psychotherapy one might receive from a qualified
clinician. It offers no guidance for people trying to decide what kind of
therapy will help them.
What about studies that compare evidence-based therapies to legitimate
alternative therapies? Such studies are scarce but their results are clear
Bamboozled by Bad Science
The first myth about "evidence-based" therapy
Published on October 31, 2013 by Jonathan Shedler, PhD in Psychologically Minded
Media coverage of psychotherapy often advises people to seek
"evidence-based therapy."
Few outside the mental health professions realize the term
evidence-based therapy is a form of branding. It refers to
therapies conducted by following instruction manuals, originally
developed to create standardized treatments for research trials.
These "manualized" therapies are typically brief, highly
structured, and almost exclusively identified with cognitive
behavioral therapy or CBT.
Academic researchers routinely extoll the evidence-based
therapies studied in research laboratories and denigrate
psychotherapy as it is actually practiced by most clinicians in
the real world. Their comments range from the hysteric (The disconnect between what clinicians do
and what science has discovered is an unconscionable embarrassment.Professor Walter Mischel,
quoted in Newsweek) to the seemingly cautious and sober (Evidence-based therapies work a little
faster, a little better, and for more problematic situations, more powerfully.Professor Steven Hollon,
quoted in the Los Angeles Times). Even former American Psychological Association president Alan
Kazdin jumped on the bandwagon, telling Time Magazine that the kind of treatment most therapists
provide is overrated and outdated and lamenting that it is hard to find referrals for evidence-based
treatments like cognitive-behavioral therapy.
Jonathan Shedler, PhD, is a Clinical
Associate Professor of Psychology at
the University of Colorado School
of Medicine.
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and consistent: they show no advantage whatever for evidence-based
therapies. An analysis published in the prestigious Clinical Psychology
Review explored the topic in depth. As control groups more closely
approximate legitimate psychotherapy provided by real clinicians (any kind
of legitimate therapy), any apparent advantage for evidence-based
therapy vanishes. Writing in careful academic language, the authors
conclude: There is insufficient evidence to suggest that transporting an
evidence-based therapy to routine care that already involves
psychotherapy will improve the quality of services.
The same article offers a truly disturbing glimpse into psychotherapy
research trials: interventions provided to control groups and labeled
Treatment As Usual by the original researchers were predominantly
treatments that did not include any psychotherapy. In other cases,
so-called Treatment As Usual involved hobbled pseudo-therapy where
therapists were prevented from using interventions they would normally
use. The authors expressed their frustration with such disingenuous
research practices in, again, understated academic tones: Training
therapists to prevent them from using certain therapeutic actions that are
typically employed in their practice cannot logically be classified as a
Treatment As Usual.
Another way to evaluate how evidence-based therapies compare to
real-word therapy is through naturalistic (versus experimental) studies.
Naturalistic studies evaluate patients treated by ordinary clinicians in their
practices. The patients are assessed before and after treatment to
measure improvement, or effect size. The effect size can then be
compared to effect sizes for evidence-based therapies from published
research trials.
An especially rigorous naturalistic study published in the Journal of
Consulting and Clinical Psychology followed 5,704 depressed patients
who received real-world therapy from licensed clinicians covered by their
health insurance plans.
The clinicians were not specially trained or
qualified; they were ordinary practitioners with masters degrees or higher
in psychology, marriage and family therapy, clinical social work, psychiatry,
or psychiatric nursingnot a high power group by any means. The effect
sizes obtained by the real-world clinicians were no different from those for
evidence-based therapies obtained in research trials. Five published
studies used comparable methods to evaluate real-world therapy. None
showed an advantage for evidence-based therapy.
Even these studies overestimate the benefits of evidence-based therapy
because published effect sizes for "evidence based" therapy are skewed
by publication bias: studies with favorable results are more likely to be
published than studies with unfavorable results. Publication bias plagues
many areas of research and creates the impression that treatments work
better than they really do. In research on evidence-based therapy,
publication bias appears extreme: an analysis in the British Journal of
Psychiatry calculated that published effect sizes for CBT are inflated by
60% to 75% due to publication bias.
In other words, the real benefits of
the therapy are less than half what is portrayed in the research literature.
If evidence-based therapies were compared to real-world psychotherapy
on a level playing field by accounting for publication bias, the findings
would show real-world therapy to be superior.
Claims that "evidence-based therapy is more effective than real-world
therapy lack any scientific basis.
This is not just my conclusion. It is also the conclusion of a blue-ribbon
panel of research experts commissioned by the American Psychological
Association to evaluate the psychotherapy research literature. It is spelled
out in an official policy statement by the American Psychological
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misunderstandings surrounding evidence-based therapy, I am providing
references and links to key articles, below. They provide the background
necessary to evaluate the research literature for yourself:
Wachtel, P.L. (2010). Beyond ESTs: Problematic assumptions in the
pursuit of evidence-based practice. Psychoanalytic Psychology, 27,
Parker, G. & Fletcher, K. (2007). Treating depression with the
evidence-based psychotherapies: a critique of the evidence. Acta
Psychiatrica Scandinavica, 115, 352359.
Westen, D., Novotny, C.M., Thompson-Brenner, H. (2004). The empirical
status of empirically supported psychotherapies: Assumptions, findings,
and reporting in controlled clinical trials. Psychological Bulletin, 130,
Beutler, L.E. (2009). Making science matter in clinical practice: Redefining
psychotherapy. Clinical Psychology: Science and Practice, 16, 301-317.
American Psychological Association (2013). Recognition of
Psychotherapy Effectiveness. Psychotherapy, 50, 102-109.
Duncan, B.L. & Miller, S.D. (2006). Treatment manuals do not improve
outcomes. In J.C. Norcross, L.E. Beutler, R.F. Levant (Eds.),
Evidence-based practices in mental health: Debate and dialogue on the
fundamental questions (pp. 140-149). Washington, DC: American
Psychological Association.

Wampold, B.E., Budge, S.L., Laska, K.M., Del Re, A.C., Baardseth, T.P.,
Fluckiger, C., Minami, T., Kivlighan, D.M., Gunn , W. (2011)
Evidence-based treatments for depression and anxiety versus
treatment-as-usual: A meta-analysis of direct comparisons. Clinical
Psychology Review, 31, 13041312.
Minami, T., Wampold, B.E., Serlin, R.C., Hamilton, E.G., Brown, G.S.,
Kircher, J.C (2008). Benchmarking the Effectiveness of Psychotherapy
Treatment for Adult Depression in a Managed Care Environment: A
Preliminary Study. Journal of Consulting and Clinical Psychology, 76,
Cuijpers, P., Smit, F., Bohlmeijer, E., Hollon, S. D., & Andersson, G.
(2010). Efficacy of cognitive behavioural therapy and other psychological
treatments for adult depression: Meta-analytic study of publication bias.
British Journal of Psychiatry, 196, 173178.

2013 by Jonathan Shedler
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