Medical approach to psychotherapy challenged

By Kerry Hill

The delivery of medical care operates, for the most part, on a familiar model: Physicians, using accepted empirically supported guidelines, prescribe specific drugs and other treatments for patients diagnosed with specific illnesses or conditions.

This approach — the accepted standard for addressing ailments that have a known biological basis — increasingly has been applied to the treatment of mental and emotional disorders and conditions, even though the understanding of causes and effects isn’t always scientifically definitive. Yet, in this era of managed health care and cost containment, the medical approach to psychotherapy has caught on, at the expense of the traditional healing approach to therapy.

In a movement that has picked up steam since the mid-1990s, the medical establishment has pursued psychotherapy — identifying the single best treatment for each particular disorder, in much the same way the Food and Drug Administration tests and approves medications. This has led to treatment manuals that dictate which therapy and how much should be prescribed to alleviate specific conditions.

Bruce Wampold has emerged as a voice among those who are challenging this trend.

Wampold, professor and chair of the Department of Counseling Psychology, whipped up a storm with his book, “The Great Psychotherapy Debate: Models, Methods, and Findings,” which he based on his comprehensive review of the research on psychotherapy. His meta-analytic research and review of other research consistently demonstrate a lack of scientific justification for the belief that the benefits of psychotherapy derive from the specific ingredients of a particular therapy.

Wampold’s work has become a lightning rod. He says those who want to “package therapy like pills” have accused him of being unscientific. “I’m the thorn in the side of people who want to dictate the type of treatment for particular disorders,” he notes.

At the same time, humanists — opponents of the medical model — hail his work as a milestone. Wampold sees his approach as both scientific and humanistic and, in the long run, believes that it will deliver the most effective mental health services.

He cites evidence that psychotherapy works well — more than 10 times more effective than many commonly accepted medical treatments. After comparing the relative effectiveness of specific therapies, however, he discovered surprisingly few differences among psychological treatments.

Effective therapy, Wampold explains, depends to a great extent on the therapist, which he regards as an “ignored but critical factor” in explaining outcomes. Positive results depend on trusting therapist-client relationships and a shared belief that therapy works. The effective therapist provides the client with a rationale for a client’s problems and then ensures that all therapeutic actions are consistent with this rationale.

Studies have revealed significant variations of outcomes among therapists, says Wampold, who adds, “We don’t really know why. We have some ideas. That’s the fundamental question I want to study.” He recommends using the outcomes of individual therapists to improve the effectiveness of services and providing constructive feedback, especially to help those who don’t do as well improve their practice. He acknowledged, however, that there is some resistance to this.

Wampold also recommends that insurers not put limits on the number of client visits. He says those who get better rarely continue therapy beyond a reasonable length of time. In most instances, clients improve rapidly, regardless of the type of therapy, and end therapy when they are functioning adequately.

Wampold’s findings and recommendations have continued to meet with some resistance from clinical scientists and managers of care who want to identify particular treatments for particular disorders and limit the length of treatments. He says, “Ideas don’t always prevail based on the evidence.”