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Psychotherapy: The Humanistic (and Effective) Treatment

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  • University of Wisconsin--Madison and Modum Bad, Norway

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Although it is well established that psychotherapy is remarkably effective, the change process in psychotherapy is not well understood. Psychotherapy is compared with medicine and cultural healing practices to argue that critical aspects of psychotherapy involve human processes that are used in religious, spiritual, and cultural healing practices. A model of psychotherapy is presented that stipulates various aspects that involve uniquely human characteristics. Central to this model is patient acquisition of an adaptive explanation of his or her difficulties. Finally, the research evidence for this model is presented.
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Psychotherapy: The Humanistic
(and Effective) Treatment
Bruce E. Wampold
University of Wisconsin—Madison
Although it is well established that psychotherapy is
remarkably effective, the change process in psychotherapy
is not well understood. Psychotherapy is compared with
Editor’s Note
Bruce E. Wampold received the Award for Distinguished
Professional Contrubutions to Applied Research. Award
winners are invited to deliver an award address at the
APA’s annual convention. A version of this award address
was delivered at the 115th annual meeting, held August
17–20, 2007, in San Francisco, California. Articles based
on award addresses are reviewed, but they differ from un-
solicited articles in that they are expressions of the win-
ners’ reflections on their work and their views of the field.
857November 2007
American Psychologist
medicine and cultural healing practices to argue that critical
aspects of psychotherapy involve human processes that are
used in religious, spiritual, and cultural healing practices. A
model of psychotherapy is presented that stipulates various
aspects that involve uniquely human characteristics. Central
to this model is patient acquisition of an adaptive explanation
of his or her difficulties. Finally, the research evidence for
this model is presented.
Keywords: psychotherapy, psychological treatments, contex-
tual model, efficacy, humanistic treatment
Psychotherapy is a remarkably effective healing practice.
Yet the mechanisms by which psychotherapy creates
change are not well understood. In an attempt to under-
stand the mechanisms of change in psychotherapy, I com-
pare psychotherapy with several other healing practices,
highlighting how the psychological processes that distin-
guish psychotherapy from other healing practices are criti-
cal to an understanding of how change occurs. I focus spe-
cifically on aspects of psychotherapy that are uniquely
human and are orthogonal to the specific ingredients of
various treatments. Finally, I demonstrate how psychother-
apy process and outcome research, as well as research
from related areas, comports with the humanistic aspects of
psychotherapy.
Classifying Healing Practices
A crucial step in understanding a phenomenon involves
scientific categorization. Scientific categorization depends
on classifying the phenomenon and related phenomena on
the basis of essential rather than superfluous characteristics
(Boyer, 1990). Psychotherapy is a healing practice, seem-
ingly similar to some other healing practices and unlike
many others, depending on the characteristics that one
makes salient. Through description and discussion of six
exemplars of human change, the characteristics that are
deemed important in psychotherapy become apparent.
Peter, a Native American, is depressed, abuses alcohol,
and has occasionally suicidal thoughts. On a return trip
to the reservation where he grew up to visit his ill
grandmother, he runs into a childhood friend, who ar-
ranges a traditional sweat for him and his family. As a
result, he develops a relationship with a traditional
healer, who removes evil spirits. Peter’s problems
lessen and he returns to work.
Susan, who experiences acute pain in her gut periodi-
cally during the day, presents to her physician, who
orders laboratory studies that confirm her suspicion that
she is suffering from a gastric ulcer. Susan begins a
regimen of antibiotics and a proton pump inhibitor,
which reduce her symptoms. After the course of treat-
ment is finished, laboratory studies are negative.
Serena, in middle age, presents to a psychologist be-
cause she is suffering from chronic anxiety about many
aspects in her life, has periodically exhibited many
symptoms of depression, and complains of a lack of
romantic and intimate relationships in adulthood, and
she receives a diagnosis of generalized anxiety disorder.
Her experiential therapist explores the death of her fa-
ther and her mother’s series of boyfriends, helping her
process her feelings with regard to these events and the
actors, and has her express previously repressed grief.
Her symptoms gradually decrease over the course of
therapy.
Wilhelm has led a particularly unremarkable life, earn-
ing just enough to support his hedonistic lifestyle,
which included recreational drugs, alcohol, snowboard-
ing, and women. Feeling increasingly lonely, he agrees
to attend church with his current girlfriend. After a pe-
riod of erratic church attendance, he breaks up with the
woman, but seeks solace from some people at the
church, including the minister. Soon thereafter, he is
born again, gives up his hedonism, and becomes a
practicing evangelical Christian.
James feels lethargic, sleeping 10 –12 hours per day.
His attendance at work is erratic, as he avoids several
situations that he finds stressful, and he no longer has
an interest in previously enjoyable activities. He pre-
sents to his internist, who explains that he is depressed,
that depression is caused by a chemical imbalance in
his brain, and prescribes a selective serotonin reuptake
inhibitor (SSRI). In about two weeks, he reports in-
creased energy and enjoyment of various activities.
Pat is suffering from symptoms of posttraumatic stress
disorder (PTSD) as a result of military service in Iraq.
She is referred to a psychologist, who administers the
standard cognitive– behavioral treatment (CBT), includ-
ing relaxation, cognitive restructuring, and prolonged
exposure. After 20 sessions, the symptoms diminish,
and she no longer meets the diagnostic criteria for
PTSD.
These six exemplars can be categorized in various ways,
and each categorization reveals something about the pur-
ported mechanisms of change involved. Putting aside a
readily apparent classification based on professions—two
treatments are delivered by physicians, two by psycholo-
gists, and two by religious figures— classifications could
also be based on explanatory systems, scientific validity,
and adherence to a medical model, as depicted in Figure 1.
Explanatory Systems
Essentially, there are three systems involved in the six
treatments: biological, psychological, and religious/spiri-
tual. The bases of the two medical treatments, antibiotics
and antidepressants, are biological. Philosophically, medi-
cine rests on the concept of materialism, which considers
matter as the sole basis of reality and, thus, attempts to
explain phenomena as the consequence of the interaction of
matter. Applied to medicine, materialism implies that any
858 November 2007
American Psychologist
bodily state—including, most importantly, illness— has a
physical substrate, and treatment involves altering some
biological system. Treatment of depression with SSRIs,
one of the change exemplars, makes the assumption that
the disorder has a biological explanation involving, in part,
neurotransmitters and that the biological intervention spe-
cifically remediates this biological cause of the disorder.
Similarly, the treatment for the gastric ulcer specifically
reduced the population of H. pylori, the biological cause of
the gastric ulcer. In addition, to be established as bona fide
medical practices, medical interventions must produce ben-
efits over and above what can be achieved by means of
hope, expectation, or relationship with a healer—that is, it
must be shown that the treatment is more effective than a
placebo.
Two of the treatments, CBT and experiential treatment,
rely on psychological explanations and would be classified
as psychotherapies. Of course, the particular psychological
explanations underlying these two treatments are quite dif-
ferent. The explanatory systems of the three main forces in
psychotherapy—psychodynamic, behavioral, and humanis-
tic— offer dramatically different psychological explanations
for various disorders. The variability in psychological ex-
planations has given rise to a plethora of psychotherapies,
numbering in the hundreds. In this regard, the class of
treatments based on psychological explanations, character-
ized by a variety of explanations of the same disorder and
a large number of treatments, differs from the class of
treatments based on biological explanations, characterized
by modal explanations of a disorder and a small number of
treatments.
So far, I have classified antibiotics and SSRIs as biolog-
ical and CBT and psychodynamic/experiential as psycho-
logical on the basis of the systems used to explain the dis-
order and construct the treatment. In contrast, the Native
American and Christian exemplars belong to a class whose
Figure 1
Three Classifications of Healing Practices
Explanatory Systems
Biological
Psychological Supernatural
Antibiotic for
Gastric Ulcer
Antidepressant for
depression
CBT for PTSD
Experiential Tx
for GAD
Native
American
rituals
Born Again
Scientific
Non-scientific
Antibiotic for
Gastric Ulcer
Antidepressan
t for
depression
CBT
for
PTSD
Native American
rituals
Born Again
Scientific Validity
Experiential Tx
for GAD
Antibiotic for
Gastric Ulcer
Antidepressant
for depression
CBT for PTSD
Medical v. Contextual
Contextual Model
Medical Model
Antibiotic for
Gastric Ulcer
Antidepressant
for depression
Experiental Tx for
GAD
CBT for PTSD
Native American
rituals
Born Again
Note. CBT ! cognitive–behavioral treatment; PTSD ! posttraumatic stress disorder; tx ! treatments; GAD ! generalized anxiety disorder.
859November 2007
American Psychologist
explanations are based on what might be characterized as
supernatural, religious, or spiritual. The bases of supernatu-
ral, religious, and spiritual treatments appear, at first
glance, to be orthogonal from the empirical foundations of
science, which leads to a second scheme for categorizing
healing practices.
Scientific Validity
Consider another classification, one based on the scientific
validity of the treatment, using the principles of the medi-
cal model. Scientific validity in medicine rests on an em-
pirical demonstration of materialism in that it must be
shown that substances and procedures that constitute medi-
cal practice are beneficial because of their direct effects on
the anatomy and physiology of the patient. The term speci-
ficity is used to indicate that a treatment works through the
hypothesized biological mechanisms. Stephen Jay Gould
(1989) cited the demonstration that the effectiveness of
Franz Anton Mesmer’s treatments was not due to animal
magnetism as one of the crown jewels of the scientific
method. The establishment of specificity in medicine was
made possible by the development in the mid-20th century
of the randomized double-blind placebo control group de-
sign, which by 1980 was required for the approval of drugs
by the Food and Drug Administration (Shapiro & Shapiro,
1997b). With regard to medical treatments, the scientific
method requires the establishment of biological mecha-
nisms of a disorder as well as the demonstration in a clini-
cal trial that the administration of a substance to treat the
disorder had effects attributable to specific ingredients. The
two medical treatments, the antibiotic treatment of gastric
ulcer and the antidepressant treatment of depression, meet
the standards to be classified as scientifically valid.
The scientific validity of various psychotherapies raises
some thorny issues. A case has been made that psychother-
apy is an amalgam of treatments, some of which meet suf-
ficient criteria to be called scientific and others of which do
not. This distinction has been made notably by David Bar-
low (2004), who discussed two classes of talk therapies:
psychological treatments and generic psychotherapy. Psy-
chological treatments, built on characteristics found in a
variety of treatment, including “the therapeutic alliance, the
induction of positive expectancy of change, and remoral-
ization,” contain important “specific psychological proce-
dures targeted at the psychopathology at hand” (Barlow,
2004, p. 873). Treatments lacking the specific psychologi-
cal procedures to which Barlow refers would be designated
as generic psychotherapy, whereas those containing the
ingredients would be psychological treatments. Barlow’s
distinction between psychological treatments and generic
psychotherapy rests on the specificity of action, the very
notion that is one of the defining features of the medical
model (Wampold, 2001b). That is, psychological treat-
ments, while using the talk and context of therapy as
means of delivery, provide ingredients that demonstrably
remediate psychological deficits and produce observable
benefits. Generic psychotherapy, however, may create
change through creating hope, remoralization, and changed
expectations and beliefs. However, these are the very
mechanisms often used to explain, in psychological terms,
change attained in religious and indigenous healing prac-
tices, thus further distancing “generic” psychotherapy from
a classification as a scientific treatment. The distinction
between treatments based on scientific psychology (i.e.,
behavioral therapy) and those based on mentalistic and un-
observable constructs (e.g., most notably, psychoanalysis)
was made at the origins of behavioral approaches (e.g.,
Eysenck, 1952, 1961, 1966; Watson & Rayner, 1920; see
also Wampold, 2001b).
Because CBT for PTSD is based on sound psychologi-
cal principles and has been shown to be efficacious in sev-
eral clinical trials (Foa, Rothbaum, Riggs, & Murdock,
1991), a case could be made that it belongs to the category
containing scientifically valid treatments. However, many
would contend that experiential treatment of generalized
anxiety disorder would fail to meet the criteria used to es-
tablish scientific validity, because this approach to treating
generalized anxiety disorder has not been manualized, has
not been found to be efficacious in clinical trials, and does
not rest on canonical psychological theory and research.
From a scientific perspective, change accomplished in
religious or cultural practice has been mostly dismissed
(Shapiro & Shapiro, 1997b). It could be argued that the
change was nonexistent in the sense that it was reported by
a practitioner or client but was not documented scientifi-
cally. An alternative explanation is that the change was
palliative only in that the recipient of the practice felt bet-
ter but the underlying pathology, either biological or psy-
chological, was unchanged. Finally, if change is docu-
mented, it could be attributed to the placebo effect (i.e.,
healing occurred but not through specified mechanisms), an
explanation which has been relegated to the backwaters of
medicine and psychology (Shapiro & Shapiro, 1997a,
1997b; Wampold, Imel, & Minami, 2007; Wampold, Mi-
nami, Tierney, Baskin, & Bhati, 2005). In this respect, ex-
periential treatment of generalized anxiety disorder would
be classified with the two religious/spiritual/cultural treat-
ments, in that this treatment has not met the criteria gener-
ally accepted by the scientific community as necessary to
qualify as scientifically valid.
Medical Versus Contextual Models
Jerome Frank (Frank & Frank, 1991) has proposed a dif-
ferent classification scheme, one in which psychotherapy is
considered a cultural healing practice, more in line with
religious and indigenous healing practices than with medi-
cal treatments. According to Frank and Frank, healing
practices involve an emotionally charged and confiding
860 November 2007
American Psychologist
relationship with a healer, a healing setting, a rationale or
conceptual scheme, and procedures that both the healer and
patient believe in and that involve active participation and
positive expectations for change. According to this per-
spective, these aspects of healing practices are the critical
ingredients of the treatment, whereas in medicine it is the
medicine’s direct effect on the biological system. What the
healing practices in the latter category have in common is
that they appear to be embedded in a cultural context, rely
on the interaction between the healer and the recipient of
the treatment, and involve an interpretation of events and
their meaning.
Modern medical treatments purportedly can be differen-
tiated from cultural healing practices because medical prac-
tices have a scientific biological basis and have been sub-
jected to the challenge of placebo-controlled trials.
Although it is recognized that cultural context and patient
preferences and expectations are important factors in medi-
cine, the emphasis of evidence-based practice in medicine
is on the effect that substances or procedures have on the
biological system over and above effects of a placebo. Ac-
cordingly, the classification of the six change exemplars
now contains two categories, medicine and a relatively am-
biguous class that might generate labels such as traditional,
cultural, indigenous, or simply other. Of course, such a
classification is politically problematic, for it associates
psychotherapy with a variety of practices that, while per-
haps not ineffective, have not been empirically shown to
be effective (Shapiro & Shapiro, 1997b).
Where Does Psychotherapy Fit?
The practice of psychotherapy, in which two conspecifics
engage in a verbal/symbolic interaction with the intent to
heal, is unique to humans. That is, psychotherapy is not a
healing practice that can be used with nonhumans in the
manner, say, that modern medicine is practiced with ani-
mals (i.e., veterinary medicine). When viewed from this
perspective, psychotherapy does appear close (perhaps un-
comfortably close) to various religious and cultural prac-
tices, as Frank and Frank (1991) have proposed. In some
way, psychotherapists walk a precarious epistemological
tightrope. Psychotherapists use the language and research
tools of medicine and science but employ treatment proce-
dures that may depend on the same psychological machin-
ery as religious, spiritual, and culturally indigenous inter-
ventions. The thesis offered here resolves this tension by
positing that the change process in psychotherapy occurs to
a large extent in the context of the human interaction be-
tween therapist and patient in ways that are consistent with
theory and research in cultural anthropology, evolutionary
psychology, and related areas and, thus, is scientific.
I now turn to a discussion of the aspects of the psycho-
therapy process that involve the communication between
the therapist and the patient and how that communication
is not simply a necessary condition for the remediation of a
dysfunction but is the primary mechanism of change.
The Humanistic Aspects of the Contextual Model
Human Abilities and Psychotherapy
The human brain is not simply a more advanced computing
device than those possessed by nonhuman animals. That is,
the distinction between humans and nonhuman animals
extends beyond the notion that human brains have more
storage, faster processors, and advanced circuitry, which
can then be applied to multiple and more complex tasks.
Rather, the human brain evolved with certain specific pro-
pensities that contain specific logics and convey certain
adaptive advantages.
1
For example, humans have a special-
ized ability to detect and recognize faces as opposed to
other similarly complex but less important objects (Boyer,
2001; Boyer & Barrett, 2005). Several of these specific
capabilities are intimately involved in the process of psy-
chotherapy and may be at least partly responsible for the
benefits experienced by patients.
One of the specific strengths of the human brain is re-
lated to interpreting events, constructing explanations, and
attributing causality (Gardner, 1998; Thomas, 2001). Reli-
gion and science are two, albeit very different, comprehen-
sive systems for explaining phenomena. Not surprisingly,
the propensity to construct explanations has been applied to
bodily phenomena as well, and thus, the very origin of hu-
mans is associated with efforts to explain and treat illness:
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 physician, 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 psycho-
logical effect. (Shapiro & Shapiro, 1997b, p. 3)
Indeed, it is impossible to identify historically any civi-
lization in which medicines, rituals, and healers were not
central features of the culture. These practices and their
accompanying explanations were generated by the prevail-
ing metaphysical zeitgeist of the society. According to the
Pythagoreans, for example, matter was composed of four
basic elements— earth, air, fire, and water—and analo-
gously, the body was composed of four humors— blood,
phlegm, yellow bile, and black bile. Personalities were
1
I make much of the distinction between humans and nonhuman ani-
mals. However, several of the abilities discussed here are exhibited in
nonhuman primates (e.g., theory of mind, empathy, culture) but are only
more developed in humans (see, e.g., de Waal, 2005). It is intriguing that
the line of demarcation between humans and nonhuman primates has be-
come increasingly murky as a result of advances in primatology. How-
ever, I suggest that the mechanisms of psychotherapy can be clarified by
focusing on the traits that are the relative strengths of the human animal.
861November 2007
American Psychologist
manifestations of mixtures of humors (the word tempera-
ment coming from the Greek temperamentum, meaning a
blending of humors), which created health when balanced
and illness when unbalanced (Morris, 1997). The Apache
shaman, whose power derived from a special status among
the spirits or from possession of a sacred object, adminis-
tered rituals to replace evil spirits with protective ones that
involved dances, drums, rattles, prayers, and chants led by
the shaman elaborately dressed in animal skins and masks
(Morris, 1997). Traditional Chinese medical practices,
which have persisted for more than 2,500 years and are
described in the I Ching (Book of Changes) and the Huang
Ti Nei Ching Su Wen (The Yellow Emperor’s Classic of
Internal Medicine), entail five tastes, five types of grain,
and five flavors, supplemented by acupuncture (Shapiro &
Shapiro, 1997b). Societies continue to evolve in their con-
ceptualization of illness and treatment, notwithstanding the
advances of modern medicine (Morris, 1998).
Various explanatory systems use different knowledge
claims as support. For example, evolution comports with
scientific evidence and creationism comports with scripture,
yet to their respective adherents, they are particularly per-
suasive explanations for the world. That one explanation is
poppycock to those who believe in the other does not de-
tract from the power of the explanation for the believers. A
commonality of all psychotherapies is that they are based
on particularly compelling explanatory systems, at least to
their adherents.
A second feature of the evolving human brain was the
capacity to expand social networks and the use of language
to manage those networks (Gardner, 1998). Language be-
came a means to convey information, influence others, and
form communities. A case can be made that language is a
means to extend cognitive processes beyond the individual;
indeed, it may be that “language evolved, in part, to enable
such extensions of our cognitive resources within actively
coupled systems” (Clark & Chalmers, 1998, p. 17). Ac-
cordingly, psychotherapy is not simply the vehicle for the
delivery of psychological ingredients but is, rather, a highly
entwined system that uses language to construct or, better
said, reconstruct the patient’s interpretation of the world. In
the latter part of the 20th century, psychotherapy was con-
sidered by some to be a social influence process (Heppner
& Claiborn, 1989), but this view has become less promi-
nent in recent years.
A third aspect of the human brain related to psychotherapy
is the propensity to make inferences about the internal states
of others, particularly their goals, desires, motivations, and
beliefs (Boyer & Barrett, 2005; Hutto, 2004; Stich & Ravens-
croft, 1994; Thomas, 2001). This propensity—variously
referred to as theory of mind or folk psychology, depending
on how it is conceived—is essentially an individual’s “de-
scription and explanation of mental function” (Thomas,
2001, p. 3). These descriptions allow humans to make pre-
dictions about others, to discriminate between predators
and prey, and to create adaptive social groups. According
to Boyer and Barrett (2005), this capability leads to “coali-
tional alliance, based on a computation of other agents’
commitments to a particular purpose. . . . as well as the
development of friendship as an insurance policy against
variance in resources” (p. 109). Although there are com-
monalities among folk psychologies across cultures, there
are cultural variations as well (Thomas, 2001). What is
clear is that the explanations of mental functioning by the
layperson typically differs from the explanations of scien-
tific psychology; in the language of Boyer and Barrett
(2005), the “human brain’s intuitive ontology is philosophi-
cally incorrect (p. 99). It is my contention that the pa-
tient’s idiosyncratic explanations of mental functions are
deeply involved in creating the patient’s problems, that
psychotherapy is intimately involved in altering these ex-
planations, and that “scientific” psychology plays a second-
ary role in this process of change.
The premise offered here is that the relative strengths of
the human mind (relative to other animals) facilitated the
development of psychotherapy as a cultural healing prac-
tice, and these psychological processes are critical to any
understanding of the efficacious ingredients of psychother-
apy. The model presented here, which has been presented
in various forms over the years (most notably by Frank &
Frank, 1991), is grounded in psychological and anthropo-
logical science and is consistent with research evidence
produced in psychology and medicine (Wampold, 2001b).
The Change Process
Briefly, I describe the change process in a humanistic con-
text. More expansive explanations have been provided else-
where (Imel & Wampold, in press; Wampold, 2001b;
Wampold, Imel, Bhati, & Johnson-Jennings, 2006).
Patients come to therapy because their problems are per-
sistent and troublesome. Their explanation for the troubles
are not adaptive. The maladaptive explanation—the pa-
tient’s “folk psychology,” if you will—typically has two
characteristics. First, according to the patient’s explanation,
the troubles appear to be inevitable or, if not inevitable, to
have a high enough probability of occurring that the fear of
the trouble is sufficient to be troublesome. Second, because
of the likelihood of continuing troubles, the patient feels
demoralized and will tend to be inactive with regard to his
or her problem.
The essential aspect of psychotherapy is that a new,
more adaptive explanation is acquired by the patient. The
means of acquisition of this new explanation is the verbal
interaction between therapist and patient. This conjecture
follows from theory and research in evolutionary psychol-
ogy and cultural anthropology positing that cultural prac-
tices—including those related to religion, politics, etiquette,
social hierarchy, and explanations for social, natural, and
862 November 2007
American Psychologist
bodily phenomena—are transmitted through communica-
tion in social interactions rather than through direct experi-
ence (Boyer, 2001). This is not to say that direct experi-
ence, either in sessions or between sessions, is not part of
many psychotherapies— these experiences may be a result
of the informational aspects of therapy, provide an addi-
tional source of information, or make the information more
memorable.
There are several critical aspects of acquiring a func-
tional explanation of one’s troubles (Wampold et al.,
2006). For one, a healer-provided explanation is expected
in any healing practice. A patient presenting to a physician
for a pain in the gut will not be satisfied (and will not
likely follow the treatment regimen) if he or she is pro-
vided with a treatment (say antibiotics and proton pump
inhibitors) without an explanation (e.g., an ulcer is caused
by the bacterium H. pylori). Similarly, psychotherapy pa-
tients expect an explanation for their problems. The human
brain craves the experience of understanding, and thus, the
evolution of healing practices naturally accommodated that
need by incorporating an explanation in all such practices.
Yalom (1995) succinctly summarized the importance of
explanation:
The unexplained— especially the fearful unexplained— cannot
be tolerated for long. All cultures, through either a scientific
or a religious explanation, attempt to make sense of chaotic
and threatening situations. . . . One of our chief methods of
control is through language. Giving a name to chaotic, unruly
forces provides us with a sense of mastery or control. (p. 84)
Another consideration is that the explanation is provided
in the context of a treatment, which is critical to the
change process. Whereas the patient’s original explanation
created an expectation that action would not alleviate the
distress, acquisition of a functional explanation creates the
expectation that if the treatment protocol is followed, the
difficulties experienced by the patient are not inevitable
and, therefore, are resolvable. This process can be concep-
tualized in several ways, some of which involve the con-
structs remoralization (Frank & Frank, 1991), response
expectancies (Kirsch, 1985), outcome expectations (Green-
berg, Constantino, & Bruce, 2006), and self-efficacy (Ban-
dura, 1997). An explanation is functional in that it pro-
duces the expectation that the patient’s problems or
troubles are not inevitable provided the treatment protocol
is followed. Acquisition of the functional explanation, ac-
cording to Jerome Frank (Frank & Frank, 1991), is remor-
alizing, and according to Irving Kirsch (1985) it changes
response expectancies. This formulation is also consistent
with the research evidence that most symptom change actu-
ally occurs in the first few sessions, before full implemen-
tation of the treatment protocol (e.g., Illardi & Craighead,
1994).
Psychotherapy treatments usually lead patients to partic-
ipate in useful activities, such as thinking more positively
about their world, expanding their social networks, commu-
nicating more effectively, substituting adaptive emotions
for maladaptive ones, and so forth. The treatments also
typically involve primary processes such as conditioning,
reinforcement, and modeling. However, the critical feature
of the treatment is that it is consistent with the acquired
explanation and leads to adaptive responses.
A corollary of the centrality of explanation and treat-
ment to psychotherapy is that any talk treatment without
these two critical elements is not a bona fide psychotherapy
as conceptualized here (see Wampold, 2001b; Wampold et
al., 1997). As such, there exists no “generic psychother-
apy” as described by Barlow (2004)—a relationship with a
warm therapist who responds empathically is not psycho-
therapy.
2
Put another way, explanation and a treatment are
essential common factors of psychotherapy. In the research
context, any control group that receives interventions with-
out these two elements, as is the case for attention control
groups or in supportive counseling, constitutes inappropri-
ate control conditions to rule out common factors.
A critical consideration is that of the importance of the
“truth” of the explanation. I argue here that the truth of the
explanation is unimportant to the outcome of psychother-
apy. The power of the treatment rests on the patient ac-
cepting the explanation rather than whether the explanation
is “scientifically” correct. Arguably, the causes of most
mental disorders have not been unambiguously identified;
unarguably, it has never been demonstrated with sufficient
scientific certainty that the benefits of any psychotherapeu-
tic treatment are attributable to the remediation of some
known cause of a disorder. What is critical to psychother-
apy is understanding the patient’s explanation (i.e., the pa-
tient’s folk psychology) and modifying it to be more adap-
tive. This was well understood by Donald Meichenbaum
(1986):
As part of the therapy rationale, the therapist conceptualized
each client’s anxiety in terms of Schacter’s model of emo-
tional arousal (Schacter, 1996). . . . After laying this ground-
work, the therapist noted that the client’s fear seemed to fit
Schacter’s theory that an emotional state such as fear is in
large part determined by the thoughts in which the client en-
gages when physically aroused. . . . Although the theory and
research upon which it is based have been criticized. . . . the
theory has an aura of plausibility that the clients tend to ac-
2
Often, Rogerian client-centered counseling is provided as an example of
a psychotherapy that consists of a relationship with an empathic therapist
and no active ingredients. However, client-centered therapy is based on
an elaborate theory and involves significantly more than the provision of
empathic response. Also, current humanistic treatments have treatment
protocols as elaborate as any manualized, empirically supported treatment
(see Rice & Greenberg, 1992).
863November 2007
American Psychologist
cept: The logic of the treatment plan is clear to clients in light
of this conceptualization. (p. 370)
If acceptance of an adaptive explanation is critical, what
leads to acceptance? Theory about the transmission of cul-
ture, particularly religious concepts (see, e.g., Boyer &
Ramble, 2001), is informative. It appears that concepts,
such as religious concepts, are best acquired when they are
discrepant from currently held beliefs but do not violate an
excessive number of a person’s assumptions (Boyer &
Ramble, 2001). I hypothesize that effective explanations in
psychotherapy must be different from presently held expla-
nations for a patient’s troubles but not sufficiently discrep-
ant from the patient’s intuitive notions of mental function-
ing as to be rejected.
A corollary is that the explanation provided to the client
must be consonant with the cultural context of the healing
practice. Patients presenting to a Western physician will
expect anatomical or physiological explanations for their
problems— unbalanced chi or four humors will, if the pa-
tient is knowledgeable of Western medicine and believes in
its efficacy, be unacceptable explanations. Similarly, pa-
tients presenting to a psychologist expect some explanation
whose locus is the mind and is consonant with the pa-
tient’s folk psychology. Moreover, beyond the cultural con-
text of the practice, acceptability of the explanation de-
pends on the proximity of the explanation to the attitudes
and values of the patient and the patient’s particular socio-
cultural context. Effective therapists are skilled at monitor-
ing acceptance of the explanation and the treatment and
will modify the delivery of an explanation as necessary.
The source of the alternative notion is critical to its ac-
ceptance. Whereas the human brain is disposed to create
and believe in particular types of explanations, the source
of an explanation that is incongruent with spontaneous or
currently held beliefs must be closely evaluated by the re-
cipient. For example, “the diffusion of religious knowl-
edge, norms, and concepts generally involves particularly
authoritative figures (shamans, priests, sages, saints) whose
statements are supposedly more reliable or closer to truth
than those of average believers” (Bergstrom, Moehlmann,
& Boyer, 2006, p. 535). This makes sense, because hu-
mans, surrounded by competing messages often emitted by
others who wish to benefit from acceptance of their mes-
sages, must discriminate among conspecifics to identify
those who are acting altruistically. Thus, psychotherapy
patients need to evaluate the trustworthiness of the thera-
pist. If the patient feels understood and ascertains that the
therapist will work diligently in his or her behalf, then the
probability of accepting the explanation of psychotherapy
and the concomitant treatment is increased. This notion is
consistent with the research on the relation between early
working alliance and outcomes in psychotherapy (Horvath
& Bedi, 2002).
The focus on acquisition of a more adaptive explanation
does not reduce psychotherapy to a didactic experience in
which the client is simply informed about the adaptive ex-
planation. Psychotherapies are elaborate rituals, with com-
plex explanatory systems, designed to influence the patient
in a variety of ways. For example, behavioral therapists
focus on actions and their consequences, cognitive thera-
pists on thinking and attributions, dynamic therapists on
the unconscious, and process– experiential therapists on
adaptive emotional responses— each of the theories and
consequent treatments constitute convincing narratives that
persuasively influence patients to accept more adaptive ex-
planations for their disorders and take ameliorative actions.
It may well be that each of the therapies causes a system-
specific change in the theory-specified way, but those ef-
fects are small relative to the effects produced by psycho-
therapy in toto.
If the premise offered here is correct, one would expect
psychotherapies to be embedded in and to emerge from the
cultural landscape, for the explanations involved would
resonate with the psychotherapy community (theorists, re-
searchers, and clinicians) and be acceptable to patients.
Prior to Freud’s lecture at Clark University, “talk therapy”
was delivered in the moral, spiritual, and religious context
of the second half of the 19th century by practitioners of
the Christian Science, New Thought, and Emmanuel move-
ments (Caplan, 1998; Taylor, 1999). When psychiatry co-
opted such treatments in the United States, a materialistic,
scientific, and medical explanation was needed, which
Freud provided in his lectures at Clark University (Wam-
pold, 2001a). But further analysis arguably suggests that
psychotherapy derived from the Freudian tradition was in-
fluenced by Ashkenazic Jewish traditions, particularly Jew-
ish mysticism (Kabbalah); Gestalt and some humanistic
therapies by the Jewish experience (e.g., the Holocaust)
and traditions; and behavioral treatments, less reflective
and more instrumental, by American pragmatism (Lang-
man, 1997). Still, it is difficult to say with certainty that a
particular psychotherapy has an identifiable cultural lin-
eage. In the complex cultural milieu of the United States
and other Western venues in which psychotherapy is a pre-
dominant healing practice, locating a single cultural thread
is impossible, but there is little doubt that the practice of
psychotherapy has been influenced by historical, cultural,
and political forces. For a thorough discussion of the cul-
tural context of various types of psychotherapy, one might
see Fancher (1995), Jackson (1999), and Pilgram (1997).
The categorization used to understand psychotherapy
has included religious, spiritual, and culturally indigenous
healing practices. These practices typically involve a per-
suasive, charismatic, and culturally sanctioned change
agent; an explanatory system that is culturally embedded
but in a limited number of ways counter to the individual’s
current beliefs; and a set of rituals delivered in a way that
864 November 2007
American Psychologist
provokes emotional reaction (Frank & Frank, 1991). There
are, however, perspicuous differences between such prac-
tices and psychotherapy. First, because the practitioners of
psychotherapy are psychologists or allied professionals, and
the explanatory systems of psychotherapy are distinctly
psychological, the delivery of treatments that are not based
on sound psychological principles, such as thought-field
therapy, should not be delivered by psychologists, in my
view. Second, psychotherapy patients have a cultural ex-
pectation of psychological explanations in the same way
that medical patients expect a biological explanation. Fi-
nally, psychotherapy deviates from many healing practices
in that psychotherapy researchers have used the tools of
empirical science to demonstrate unequivocally that psy-
chotherapy is effective.
A critical question is the following: Is the human pro-
pensity to heal as a consequence of elaborate and ritualistic
practices an evolved human characteristic or an evolution-
ary by-product? In the former proposition, the ability to
heal by means of societal rituals conferred an advantage
that led to selection for this ability, which constitutes the
conventional evolutionary calculus. However, many human
activities are by-products of human abilities evolved for
other purposes. The natural selection versus by-product
debate is current in discussions of religion (see, e.g., Atran,
2002; Boyer, 2001), and the same considerations are ger-
mane to healing practices, although much less attention has
been devoted to this area.
In many ways, the model presented here is an extension
of various cultural healing and common-factors models
presented over the years by Jerome Frank (Frank & Frank,
1991), Arthur Kleinman (Kleinman & Sung, 1979), Judd
Marmor (1962), and me (Wampold, 2001b; Wampold et
al., 2006), among others. These models are not in the
mainstream of clinical science, to be sure. What is quite
remarkable, however, is that the accumulating evidence,
including research from clinical trials of psychotherapies
(considered the “gold standard”) as well as related areas,
corroborates the model presented here.
Research Support
Briefly, for reasons of space, I review the major results
from psychotherapy and related areas of research to dem-
onstrate that the results are consistent with the model of
psychotherapy presented here. This synopsis is an exten-
sion of my previous work (most particularly Wampold,
2001b).
Does psychotherapy work? As I have noted, the pur-
ported mechanisms of the contextual model are endemic to
healing practices of every culture from the beginning of the
human species. Shapiro and Shapiro (1997a, 1997b) have
cogently argued that most treatments offered over the cen-
turies were no more than placebos, involving elaborate rit-
uals and arcane mixtures of organic and inorganic sub-
stances, many of which were clearly iatrogenic. Although
these treatments have been sufficient to sustain, or at least
not annihilate, humans for many millennia, there is no par-
ticular reason to believe that psychotherapy, as conceptual-
ized in the contextual model, might alter the natural history
of a disorder. Indeed, in the middle of the 20th century,
Hans Eysenck (1952, 1961, 1966) claimed that psychother-
apy was not only ineffective but likely harmful.
It was about two decades after Eysenck’s original
claims about the ineffectiveness of psychotherapy that
Mary Lee Smith and Gene Glass (1977; Smith, Glass, &
Miller, 1980) applied meta-analysis to the myriad con-
trolled studies that existed at the time and demonstrated
that psychotherapy was, in fact, remarkably effective. The
effect size estimate yielded by Smith and Glass’s (1977;
Smith et al., 1980) meta-analysis of comparisons of pa-
tients receiving psychotherapy with those receiving no
treatment was .80 —that is, the treated patients had out-
comes .80 standard deviation units better than no-treatment
patients. Over the years, this estimate has proven to be re-
markably robust (Wampold, 2001b).
There are a number of metrics that can be used to un-
derstand an effect of the size obtained by Smith and Glass
(1977) and subsequent meta-analyses. Cohen (1988) has
classified an effect of .80 as “large” for the social sciences.
An effect of this size indicates that the average patient re-
ceiving a treatment would be better off than almost 80% of
untreated patients. Another means to understanding this
effect is to convert it to an index called the number needed
to treat (NNT), the number of patients who need to receive
the experimental treatment vis-a`-vis the comparison to
achieve one success, which is becoming the common met-
ric of evidence-based medicine. An effect size of .80 is
equivalent to an NNT of 3 (Kraemer & Kupfer, 2006)—
that is, three patients need to receive psychotherapy to
achieve a success relative to untreated patients (Wampold,
2001b). Although clearly not effective with every patient,
psychotherapy compares well with established medical
practices. For example, the NNT for aspirin as a prophy-
laxis for heart attacks, an accepted medical practice based
on a clinical trial that was discontinued because it was
thought to be unethical to withhold treatment from the con-
trol group (see R. Rosenthal, 1990), is 129. Moreover, a
perusal of the University of Toronto’s Centre for Evidence-
Based Medicine Web site reveals that psychotherapy is
more effective than many evidence-based medical prac-
tices, some of which are costly and produce significant side
effects, including almost all interventions in cardiology
(e.g., beta-blockers, angioplasty), geriatric medicine (e.g.,
calcium and alendronate sodium for osteoporosis), and
asthma (e.g., budesonide); influenza vaccine; and cataract
surgery, among other treatments. Moreover, when directly
compared in clinical trials, psychotherapy typically is as
effective as pharmacological treatments of mental disorders
865November 2007
American Psychologist
and is more enduring (e.g., Barlow, Gorman, Shear, &
Woods, 2000; Hollon, Stewart, & Strunk, 2006; Robinson,
Berman, & Neimeyer, 1990). Finally, providers in private
practice produce effects that are comparable to the effects
achieved in clinical trials of psychotherapy (Minami et al.,
in press).
Psychotherapy as a class of healing practices, along
with modern medicine, belongs to an elite club that admits
only members who have demonstrated scientifically that
their practices are effective. This elite status is a result of
the fact that clinical scientists conceptualized psychother-
apy in a medical model, which led to the use of clinical
trials as a means to produce scientific evidence. However,
establishment of effectiveness confers little in the way of
explanation for the benefits of psychotherapy. Specifically,
some would claim that the unique potent psychological
ingredients of psychotherapy are responsible for the re-
markable effectiveness of the practice, whereas others
would give primacy to the contextual processes described
earlier.
Are some psychotherapies more potent than others?
Eysenck’s (1952, 1961, 1966) evidence regarding the effec-
tiveness of psychotherapy was presented in the context of
an attempt to demonstrate that treatments grounded in sci-
entific psychology (i.e., behavioral treatments emanating
from learning theory) were superior to treatments based on
mentalistic and unobservable constructs, such as psychoan-
alytic treatments (Wampold, 2001b). When Smith and
Glass (1977; Smith et al., 1980) conducted their meta-anal-
yses showing that psychotherapy was effective, they also
claimed that when various confounding variables were con-
trolled, such as the reactivity of the measures, there were
no significant differences among treatments, a result that
contradicted Eysenck’s contention that those treatments
that were based on scientific psychological principles
would be superior. However, the general equivalence of
treatments, often called the dodo bird conjecture, comports
well with the notion presented here that it is the acceptance
of the adaptive explanation that is critical rather than the
absolute truthfulness of the psychological explanation.
A number of meta-analyses addressing the relative effi-
cacy of psychological treatments have been conducted
since Smith and Glass’s (1977), and they have reached the
same conclusion—all treatments intended to be therapeutic
are approximately equally effective, a result that detracts
from the contention that psychotherapies based on scientific
psychology will be more effective than other treatments. In
1997, Wampold et al. corroborated the dodo bird conjec-
ture in a meta-analysis of studies that directly compared
psychotherapies intended to be therapeutic. However, this
analysis was criticized on a number of grounds, the most
valid being that the studies were aggregated without regard
to particular diagnosis (e.g., Crits-Christoph, 1997). Never-
theless, I contend that there is little evidence, after decades
of clinical trials with children and adults, that for any diag-
nosis, one treatment has been shown to be demonstrably
superior to another (Wampold, 2001b; see also Miller,
Wampold, & Varhely, in press; Spielmans, Pasek, & Mc-
Fall, 2007; Wampold, 2005).
An examination of PTSD is particularly instructive. Be-
cause PTSD is a disorder that it attributable to a discrete
event or series of events, it would seem that a treatment
based on a scientific psychological explanation would be
readily accessible; indeed Foa and her colleagues (e.g., Foa
et al., 1991, 2005) have developed a treatment protocol
involving cognitive restructuring, prolonged imaginal expo-
sure, and in vivo exposure. And not surprisingly, this treat-
ment has been shown to be quite effective. Nevertheless,
several treatments with very different treatment rationales
have also been shown to be effective, including eye-move-
ment desensitization and reprocessing (e.g., Rothbaum, As-
tin, & Marsteller, 2005); cognitive therapy without expo-
sure (Tarrier et al., 1999); hypnotherapy (Brom, Kleber,
& Defares, 1989); psychodynamic therapy (Brom et al.,
1989); and, recently, present-centered therapy (PCT; Mc-
Donagh et al., 2005). How can so many radically different
treatments be approximately equally effective?
An examination of the history of PCT will illustrate
how so many different treatments can effectively be used
for PTSD. To control for common factors, cognitive com-
ponents, and exposure, Foa et al. (1991) used a control
group that was labeled supportive counseling, described as
follows:
Patients were taught a general problem-solving technique.
Therapists played an indirect and unconditionally supportive
role. Homework consisted of the patient’s keeping a diary of
daily problems and her attempts at problem solving. Patients
were immediately redirected to focus on current daily prob-
lems if discussions of the assault occurred. (p. 718)
The supportive counseling treatment was not based on es-
tablished psychological principles (i.e., there were no cita-
tions of the psychological literature in the description),
whereas the authors were instrumental in the development
of the two treatment conditions (prolonged exposure and
stress-inoculation training) and trained the therapists. De-
spite the allegiance of the researchers/trainers and the lack
of a cogent rationale for the supportive counseling, patients
in the control condition improved, although reduction of
PTSD symptoms was significantly less than that in the two
treatment conditions. When PCT appeared again in the re-
search literature (McDonagh et al., 2005), it was manual-
ized; it was based on purported psychological processes, in
this case the problem-solving literature (e.g., Nezu, Nezu,
& Perri, 1989) and the client-centered approach of Carl
Rogers (e.g., Meador & Rogers, 1973); and therapists were
trained to deliver the treatment. However, PCT was still
clearly a control group for CBT of PTSD: “PCT was spe-
866 November 2007
American Psychologist
cifically designed to omit the hypothesized active ingredi-
ents of CBT (breathing retraining, PE, in vivo exposure,
and CR)” (McDonagh et al., 2005, p. 518). In the McDon-
agh et al. study, PCT and CBT were superior to no-treat-
ment controls, and CBT and PCT were generally equiva-
lent in terms of outcomes (n.b., CBT was superior to PCT
in terms of proportion of completers not meeting PTSD
diagnostic criteria at three-month follow-up, but none of
the other eight variables for completers or intent to treat at
termination or follow-up were statistically significant). The
conclusion? When a treatment begins to resemble one that
is intended to be therapeutic— by having a manual, legiti-
mate psychological components, and therapists who are
trained to deliver the treatment—it produces effects compa-
rable to what is considered to be the gold standard of treat-
ment for PTSD. In this case, PCT was designed intention-
ally to lack the specific ingredients thought to be essential
for the treatment of PTSD (e.g., exposure), and yet it was
well received by patients (significantly fewer dropped out
than in CBT) and produced benefits comparable to CBT.
To be fair, there have been well-conducted trials that
have shown some differences between treatments intended
to be therapeutic. For example, recently, Dimidjian et al.
(2006) found that behavioral activation was superior to
CBT for severely depressed patients. However, the number
of trials that showed significant differences between treat-
ments intended to be therapeutic are what would be ex-
pected by chance under the null hypothesis of no differ-
ences (Wampold et al., 1997). More important, as
discussed below, the trials that did show differences are
not particularly informative about the remediation of psy-
chological processes that lead to distress.
What is the evidence for specific psychological pro-
cesses and their remediation? In medicine, specificity is
established in two complementary ways. First, a substance
containing the ingredient hypothesized to change a biologi-
cal aspect of the patient can be shown to produce a pre-
dicted effect compared with a placebo in a double-blinded
randomized placebo control group experiment. Second,
some variation of the following prototypical system-spe-
cific sequence also needs to be established: (a) A biological
explanation for the illness, based on scientific research, is
established; (b) a treatment is designed or a substance is
hypothesized to remediate the biological deficit; (c) admin-
istration of the substance demonstrably alters the biology
of the patient in the expected way, and other substances do
not; and (d) the change in the biology remediates the ill-
ness (a cure or management of chronic illness). Occasion-
ally, a substance has been shown to be effective for un-
known reasons, as was the case of acetylsalicylic acid
(commonly known as aspirin), which was used as an anal-
gesic, anti-inflammatory, and antipyretic agent before its
biological mechanisms were understood. During the period
that medicine adopted the placebo control group design, D.
Rosenthal and Frank (1956) recommended that it be used
in psychotherapy to establish specificity; forgotten was the
fact that they also recognized that demonstration of a psy-
chological, system-specific sequence was critical to estab-
lishing the specificity of psychotherapy.
Attempts to establish the specificity of psychological
treatments through either of the two methods used in medi-
cine have not produced convincing evidence with regard to
any treatment for any psychological disorder. Placebo-con-
trolled group designs in medicine have two requirements,
blinding and indistinguishability, neither of which is
present in clinical trials of psychotherapy (see Baskin,
Tierney, Minami, & Wampold, 2003; Imel & Wampold, in
press; Wampold, 2001b; Wampold et al., 2005). Essen-
tially, it is impossible to blind clinical trials, and placebo-
type controls do not resemble the active treatments in
terms of the model presented here. The comparison groups
used to validate psychotherapy treatments—which are often
called nonspecific, supportive counseling, or common-fac-
tors controls—are missing the most important humanistic
factors that I have discussed—simply, that they provide
patients with a viable explanation for their problems and a
set of actions that they can follow to accomplish their
goals, which are provided by a therapist who believes in
the treatment and delivers it with the expectation that it
will be effective. However, as expected in the contextual
model, when these types of controls begin to resemble
treatments intended to be therapeutic, even if they do not
have any particularly scientific psychological ingredients,
they are as effective as so-called evidence-based treatments
(Baskin et al., 2003). Indeed, as discussed above, PCT,
when manualized and given by therapists trained to deliver
the treatment, was an effective treatment for PTSD.
The best experimental design for establishing specificity
is probably the dismantling design, in which the one or
two active ingredients are removed, leaving a legitimate, if
degraded, treatment. Jacobson et al. (1996) dismantled
CBT for depression, which is arguably the most empiri-
cally established psychotherapy ever known, by systemati-
cally removing the cognitive components and found no
decrement in outcomes when critical cognitive components
were removed. Also, component studies of CBT for PTSD
have revealed that omitting critical ingredients does not
attenuate the effectiveness of CBT (e.g., Foa et al., 2005).
These are not anomalies: Ahn and Wampold (2001) com-
pleted a meta-analysis of component studies and found no
evidence to support the claim either that removing a criti-
cal ingredient of a treatment attenuated outcomes or that
adding a specific ingredient to a treatment augmented out-
comes.
Examination of the prototypical system-specific se-
quence that would establish specificity reveals a similar
lack of evidence for specificity. Of course, psychotherapy
is at a distinct disadvantage relative to medicine because
867November 2007
American Psychologist
the classification system for psychiatric disorders remains
objective– descriptive rather than etiological (Widiger &
Trull, 2007). Although many good theories exist for most
disorders, establishing the scientific basis for mental disor-
ders has proven particularly difficult. For example, panic
disorder is a relatively circumscribed disorder, but the six
best psychological explanations provided for this disorder
have either been falsified or are not falsifiable (Roth, Wil-
helm, & Petit, 2005), creating a dilemma for researchers
wishing to establish specificity in this area. Although the
neurosciences offer much promise in this regard, current
models are far from unambiguous (see Cannistraro &
Rauch, 2003). Moreover, as various treatments for panic
disorder have been manualized and tested, they have been
found to be effective, now ranging from CBT (Barlow,
Craske, Cerny, & Klosko, 1989) to psychodynamic psycho-
therapy (Milrod et al., 2007), creating havoc for attempts
to establish the specificity sequence.
Establishing the psychological bases of treatments
shown to be effective has also proven particularly trouble-
some. A salient example is systematic desensitization, one
of the earliest behavioral treatments and one that is clearly
effective. By 1977, many models—including reciprocal
inhibition, extinction, expectancy effects, cognitive reas-
sessment, and treatment credibility— had been offered to
explain the efficacy of systematic desensitization, but none
of these have been corroborated (Kirsch & Henry, 1977).
Wampold (2001b) examined various moderating and medi-
ating predictions that emanate from the specificity sequence
and could not detect any consistent evidence that any treat-
ment had established the mechanisms of action that pur-
portedly form the basis of the treatment. For the few clini-
cal trials that produced differences in outcomes between
two treatments intended to be therapeutic, the differences
between the two treatments typically were explained post
hoc and without evidence to suggest that different mediat-
ing psychological mechanism were operating (e.g., Dimid-
jian et al., 2006).
Are engagement in therapy, formation of the alliance,
and the therapist critical to successful therapy? If it is
not the particular treatment that makes a difference, what is
it? Of course, the answer is not known, but there are tanta-
lizing suggestions.
In the model presented here, engagement in the thera-
peutic process is critical, for it signals a willingness to trust
the therapist to provide an explanation that will benefit the
patient. A consideration, thus, is whether the patient is un-
willing to continue in therapy due to an incompatibility
with the therapy or the therapist. In clinical trials, in which
patients are presumably motivated to obtain the treatments
offered, approximately 26%, 14%, and 16% of patients in
depression, panic, and generalized anxiety disorder trials,
respectively, do not complete the treatment protocol, de-
spite incentives in research studies to do so (Westen &
Morrison, 2001). Sometimes there is an indication in trials
that patients find one of the treatments less acceptable than
another. For example, in the comparison of CBT and PCT
for PTSD discussed earlier (McDonagh et al., 2005), 40%
of patients in CBT dropped out prematurely, whereas only
9% dropped out of PCT. It is unfortunate that given very
small differences among treatments intended to be thera-
peutic, if they exist at all, relatively little attention is paid
to issues of attrition.
It appears that several pretherapy factors lead to engage-
ment in the therapeutic process, including a patient’s pref-
erence for treatment (Elkin, Yamaguchi, & Arnkoff, 1999;
Iacoviello et al., 2007) and expectations about improve-
ment (Connolly Gibbons et al., 2003), which supports the
notion that acceptance of the therapeutic rationale is criti-
cal. The consistent and robust finding that the working alli-
ance, which is a measure of both relationship and collabo-
ration (Hatcher & Barends, 2006), is related to outcome
(Horvath & Bedi, 2002) suggests that successful therapy
relies on the acceptance of the therapist as a trusted agent
who will act in the best interest of the patient.
There is increasing evidence that it is the therapist and
not the treatment per se that is responsible for therapeutic
change (Wampold, 2006). Essentially, it appears that even
in clinical trials in which therapists are selected for their
skill, are trained and supervised, and are monitored so as to
maintain adherence to the treatment protocol, a significant
proportion of the variability in outcomes is attributable to
therapists within treatments, and that this therapist effect is
at least one order of magnitude greater than any differences
among treatments in these trials (e.g., Kim, Wampold, &
Bolt, 2006). Moreover, it appears that much of the variabil-
ity among therapists is due to therapists’ ability to form a
working alliance with a variety of patients (Baldwin, Wam-
pold, & Imel, in press). This line of research suggests that
it is not what psychological ingredients are delivered but
how they are delivered that is crucial. Further, it appears
that better therapists are trusted by patients, the patients
accept the explanation for their problems more readily, and
they work collaboratively with the therapists to achieve
their goals.
Over the years, an impressive array of literature, sum-
marized by Norcross (2002), has emerged that supports the
notion that interpersonal aspects of psychotherapy created
by the therapist are reliably related to outcome. That these
aspects of psychotherapy cannot be studied experimentally
(i.e., that they cannot be manipulated as independent vari-
ables) does not detract from their possible importance as
causal variables; moreover, modern statistical methods that
can establish strong claims for causality from passive de-
signs are beginning to reveal support for the importance of
interpersonal variables unrelated to specific treatments.
What can we learn from placebo research? There
continues to be debate about the magnitude of placebo ef-
868 November 2007
American Psychologist
fects in medicine, although it appears that such effects are
present in medical clinical trials under the proper condi-
tions (Wampold et al., 2005). Moreover, in laboratory stud-
ies, the placebo effect can be robustly induced, affecting
physiological states as well as patient-reported internal
states (e.g., pain). The commonality in all demonstrations
of placebo effects is that the patient or subject is aware
that he or she is receiving some intervention (i.e., a sub-
stance or a procedure) and that expectations are created by
physician or researcher actions or instructions. For exam-
ple, biological studies of the placebo effect suggest that
positive expectancy for analgesia results in the release of
endogenous opioids, a substance with known analgesic ef-
fects (Amanzio, Pollo, Maggi, & Benedetti, 2001; Levine,
Gordon, & Fields, 1978). A recent study indicated that the
expectation that one will receive a less noxious taste than
previously experienced influenced activation in the primary
taste cortex even though the actual taste stimulus remained
the same—that is, expectation of taste influenced the actual
experience of taste (Nitschke et al., 2006). Placebo re-
sponse appears to be a uniquely human response, created
by expectations created in a cultural context, often in the
interaction with powerful others (physicians or researchers)
by subjects who have come to believe that the substances
or manipulations will be effective—a situation not unlike
psychotherapy (see Kirsch, 2005).
It appears that the efficacy of many medical treatments
is due largely to placebo effects. It has been demonstrated
that medical treatments delivered surreptitiously to patients
do not produce medical benefits comparable to the same
treatments delivered within a patient’s awareness (Bene-
detti, Mayberg, Wager, Stohler, & Zubieta, 2005). For dis-
orders amenable to placebo effects, when designs are ade-
quate, placebo effects are as large as treatment effects
(Wampold et al., 2005). Moreover, it appears that most of
the effect of SSRIs for depression is attributable to placebo
effects (Kirsch, Moore, Scoboria, & Nicholls, 2002). Fi-
nally, adhering to a placebo therapy versus not adhering to
the placebo therapy decreases mortality as much as does
adhering to the drug therapy (Simpson et al., 2006). Thus,
it appears that in medicine, in which biological agents have
known potency, the human factor conveyed by way of pla-
cebo is responsible for demonstrable benefits to patients.
Conclusions
“Psychology’s dual heritage,” as Messer (2004, p. 586)
observed, involves the scientific and the humanistic tradi-
tions—and this heritage has often divided the discipline.
On the one hand, the scientists have often found appli-
cations of psychology to be not particularly scientific.
Those aligned with humanistic aspects of psychotherapy,
on the other hand, have perceived scientic investiga-
tions to be focused on aspects of psychotherapy that are
irrelevant to the essence of the endeavor. Yet each per-
spective brings to the endeavor strategically important
contributions.
Although healing practices have existed since the begin-
ning of the human species, the efficacy of nearly all such
practices has not been subjected to what would be consid-
ered a scientific test. Modern medicine emerged from the
multitude of healing practices as the scientific application
of biological knowledge to cure and prevent diseases, re-
duce mortality, and prolong life. The development of ran-
domized control group designs allowed the demonstration
that the chemical ingredients of drugs produced effects be-
yond those created by the mind and established the efficacy
and specificity of these substances. The application of the
randomized design by clinical scientists to the study of
psychotherapy has robustly shown that this healing practice
is remarkably efficacious—indeed, psychotherapy is as ef-
fective as or more effective than many established medical
practices. The contributions of science to the establishment
of psychotherapy as a legitimate and effective practice
should not be underestimated.
Those interested in the humanistic aspects of psycho-
therapy tend to focus on the interpersonal relationship be-
tween therapist and patient and on the process of psycho-
therapy. Research has shown that these variables related to
the interpersonal process are robust predictors of outcome
and are likely causally involved in producing the benefits
of psychotherapy (Norcross, 2002; Wampold, 2001b).
Moreover, the focus on particular treatments as a source
of variability in outcomes has produced little evidence
that the type of treatment administered accounts for
much of the variability in outcomes or that particular
ingredients of particular treatments are necessary for the
successful treatment of particular disorders. It appears
that the focus on the therapeutic interaction as the criti-
cal aspect of psychotherapy is justified by the research
evidence.
The humanistic and the scientific strands do not need to
stand in opposition to each other. The mission of science is
to explain, discover, and understand. It is time for science
to be applied to the humanistic aspects of psychotherapy to
better understand the intricate nature of a remarkably effec-
tive healing practice.
Author’s Note
Correspondence concerning this article should be ad-
dressed to Bruce E. Wampold, Department of Counseling
Psychology, School of Education, University of Wiscon-
sin—Madison, 321 Educational Building, 1000 Bascom
Mall, Madison, WI 53706. E-mail: wampold@education
.wisc.edu
869November 2007
American Psychologist
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... Over the past 30 years there has been a long history of researchers seeking to understand underlying mechanisms of psychotherapy success, and over time numerous models of change have emerged, including but not limited to psychotherapy integration (Stricker and Gold, 1996), the common factors approach (CF; Frank and Frank, 1991;Wampold, 2007), theoretical integration (Stricker and Gold, 1996), phase models (Howard et al., 1993), and the transtheoretical states of change model (Prochaska and DiClemente, 1983). From the psychotherapy integration approach, which aims to look beyond single approaches and instead hopes to integrate multiple perspectives, to the common factors approach, which proposes that different approaches in psychotherapy share common factors that account for the majority of the effectiveness of a psychological treatment, each model has developed their own ways of assessing and understanding change in psychotherapy. ...
... The current article aims to use P007's data to identify changes in specific symptomatology over the course of treatment in order to identify if a given therapeutic intervention, or module (e.g., mindfulness) was related to downstream effects in predicted symptom domains (e.g., reduced restlessness). It should be acknowledged that some researchers have proposed that efficacy of psychotherapy is not due to specific interventions or techniques, but rather from factors of psychotherapy common to all treatments, referred to as common factors (Luborsky et al., 1975;Wampold, 2001Wampold, , 2007. Yet, the current research aims to define specific effects that can be attributed to certain interventions, rather than common factors. ...
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... Intercultural therapy trainings may help to raise awareness of cultural biases and benefits from treatment based on cultural information (e.g., Cuéllar & Paniagua, 2000), being sensitive towards clients' unique cultural perspectives (Wampold, 2007; also see Costantino & Malgady, 1994), and to understand specifics of mental health symptoms in refugees . Such trainings may also help to target the more malleable factors that we have investigated. ...
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Refugee populations show considerably high rates of mental health problems. Yet, many mental health professionals may have reservations to work with refugees due to suspected cultural differences, language barriers, and the need to provide additional services. However, little is known about psychotherapists’ readiness to work with refugees. In a sample of German psychotherapists (N = 111), we explored therapeutic style (neutrality, supportiveness, and self‐doubt), therapists’ basic assumptions (pessimism, rationality, and therapy as art), experiences, private and work‐related contact with refugees, political interests, openness, and practical barriers as potential predictors of readiness to work with refugees. Therapeutic styles of self‐doubt and neutrality, rationality as basic assumption, former experiences with refugees in a therapeutic setting, feeling comfortable working with an interpreter in therapy, and (negatively) perceived language barriers emerged as most important predictors of psychotherapists’ readiness to work with refugees. Future directions and potential interventions to promote therapists’ readiness to work with refugees are discussed.
... In addition, addressing fatalism may have an effect on symptom improvement that goes beyond increased adherence. Providing a convincing treatment rationale is most likely one of the most powerful unspecific factors in psychotherapy (Gaab et al., 2019;Wampold, 2007;Wampold & Imel, 2015). Fostering the belief that distress can be reduced and well-being can be increased through the use of psychological techniques most likely has an effect on symptoms on its own, aside from the specific effect produced by the techniques themselves. ...
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Background: In order to narrow the world-wide treatment gap, innovative interventions are needed that can be used among culturally diverse groups, e.g., immigrant populations in high-income countries. Research on cultural adaptation of psychological interventions indicates that a higher level of adaptation is associated with a higher effect size of the intervention. However, direct comparisons of different levels of adaptations are scarce and have not been done with self-help interventions. Aims: This study will use a Smartphone-based self-help programme called Step-by-Step (Albanian: Hap-pas-Hapi) for the treatment of psychological distress among Albanian-speaking immigrants in Switzerland and Germany. Two levels of cultural adaptation (i.e., surface vs. deep structure adaptation) will be compared. We hypothesise that the deep structure adaptation will enhance the acceptance and effect size of the intervention. The deep structure adaptation was done based on an ethnopsychological study to examine the target population’s cultural concepts of distress. Methods: We will conduct a two-arm, single-blind randomised controlled trial. Participants will be randomly assigned to the surface vs. deep structure adaptation version of Hap-pas-Hapi (1:1 allocation using permuted block randomization). Inclusion criteria are good command of the Albanian language, age above 18, and elevated psychological distress (Kessler Psychological Distress Scale score above 15). Primary outcome measures are the total score of the Hopkins Symptom Checklist and the number of participants who completed at least three (out of five) sessions. Secondary outcomes are global functioning, well-being, symptoms of post-traumatic stress, and self-defined problems. In addition, we will test a mediation model, hypothesizing that the deep structure adaptation will address fatalistic beliefs and enhance alliance with the self-help programme, which in turn increases the acceptance and effect size of the intervention. And finally, we will measure acculturation and hypothesise, that with higher levels of acculturation, the effect of the deep structure adaptation will diminish. Discussion: This is the first study to directly compare two different levels of cultural adaptation of an online self-help programme for the treatment of psychological distress among immigrants in high-income countries. We aim to deliver theory-driven and methodologically rigorous empirical evidence regarding the effect of cultural adaptation on the acceptance and effect size of this self-help programme.
... We have studied the dyadic experiences in 11 psychotherapy processes with a particular focus on the development of the relationship. Findings illustrate how participants in the psychotherapy process relate to each other as fellow humans and that they engage in symbolic interaction with the intent to heal (Wampold 2007). Exploring the research question about how clients and therapists develop a relationship that the client can use to develop, grow or heal, we have described this as a process of mutual engagement. ...
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... Sin embargo, en muchos casos, tampoco pueden circunscribirse en exclusiva solo a una cuestión de posicionamiento a lo largo de una dimensión, sino también a otras variables igualmente relevantes como los malestares, incomprensiones, amenazas, vacíos, motivaciones u objetivos vitales. Debido a estas razones, los sistemas de evaluación y diagnóstico tradicionales (DSM e ICD) han recibido numerosas críticas y propuestas de mejora (Barlow et al., 2013;Kazdin, 2008;Wampold, 2007). ...
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La psicología está considerada una disciplina científica, pero algunas de sus especialidades, como la psicología clínica, tienen importantes dificultades para aplicar el método científico y trasladar los resultados de la investigación experimental al contexto profesional. Esta situación es especialmente problemática cuando multitud de teorías hacen que proliferen numerosos tratamientos psicológicos y que se sustente la idea (¿equivocada?) de que todos funcionan. El enfrentamiento entre posicionamientos basados en los aspectos comunes de las psicoterapias, en confrontación con los centrados en las técnicas, ha facilitado el camino y la expansión de pseudoterapias y la confusión de la población en general. Todo esto ocurre dentro de un contexto en el que ya existía un importante desencuentro entre la ciencia y la práctica clínica que afecta a muchos ámbitos profesionales de la psicología. El debate sobre los tratamientos y la asunción de que todos son eficaces permite mantener una actitud permisiva ante el uso de cualquier tratamiento, a veces avalados por algunas universidades, colegios profesionales y sociedades científico-profesionales, sin establecer restricciones a la difusión de propuestas pseudocientíficas, que no han sido sometidas a contraste empírico. En este trabajo presentamos un análisis del estado actual del tema y debatimos algunos de los aspectos más importantes.
... Dichas variables se dividen en las del consultante, del terapeuta y de la relación terapéutica. Diversos autores plantean que es el terapeuta y no el tratamiento en sí mismo lo que determina el cambio terapéutico y los resultados de la psicoterapia (Wamplod, 2007). En este sentido se vuelve particularmente relevante estudiar el Estilo Personal del Terapeuta (EPT). ...
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El Estilo Personal del Terapeuta (EPT) se conceptualiza como un constructo multidimensional que está presente en todo proceso terapéutico. El objetivo de este trabajo fue determinar si las variables enfoque teórico, años de experiencia, sexo, grado académico y edad, predicen el EPT en psicoterapeutas y psicólogos en formación. Se administró el Cuestionario del Estilo Personal del Terapeuta (EPT-C) a una muestra de 103 sujetos. El análisis de confiabilidad indicó que sólo los factores Operativo-Atencional y Expresivo-Emocional eran analizables, realizando con ellos un modelo de Regresión Lineal Múltiple Jerárquica. Los resultados indican que la interacción entre las variables enfoque terapéutico y años de experiencia predicen el estilo Operativo-Atencional, situación que no fue observada en el factor Expresivo-Emocional.
... Ceci pourrait également contribuer à la réduction de l'effet Matthieu. À l'instar des recherches en psychothérapie ayant montré que la formation académique ne garantit pas de bénéfice thérapeutique (Wampold, 2007), ou plus récemment, dans le champ de la suicidologie, où Mishara et al. (2016) ont montré une meilleure qualité de la prise en charge téléphonique lorsqu'elle était réalisée par des para-professionnels, l'usage des para-professionnels en visite à domicile peut légitimement se poser comme un axe à investiguer. ...
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La visite à domicile (VAD) est une modalité d’intervention préventive reconnue. La littérature a documenté les meilleures conditions de sa mise en œuvre. Les programmes de VAD recourent fréquemment aux visiteurs para-professionnels. Cependant, peu de recommandations ont été formulées par rapport aux compétences relationnelles, à la formation à la VAD ou à la supervision à apporter à ces intervenants. Cette étude de portée met en avant les principales caractéristiques des interventions recourant à des para-professionnels en VAD. Les résultats portent sur le détail des formations et des supervisions, et mettent en évidence le moindre intérêt porté par les auteurs des interventions sur les compétences interpersonnelles de ces visiteurs à domicile.
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Objective: The evidence-based practice movement clearly defines the relevant components of a good treatment. In the present article, we elaborate on how the active involvement of patients within psychotherapy can and should be increased in order to respect ethical considerations. Our arguments complement the requirements of evidence-based practice, and are independent of the actual psychotherapeutic treatment approach being used. Method: Theoretical and ethical analysis. Results: In order to respect patient autonomy, psychotherapy needs to be transparent and honest when it comes to disclosing the relevant factors for promoting therapeutic change. It has been argued that ethical informed consent needs to include empirically supported patient information. In this paper we go one step further: we outline that fully respecting ethical considerations in psychotherapeutic treatment necessarily calls for acknowledging and strengthening the active role of patients in the course of psychotherapy. Accordingly, patients need not only to be informed openly and transparently about the planned treatment, the treatment rationale, and the expected prognosis of improvement in the course of psychotherapy, but they also need to be actively involved in the decision-making process and during the entire process of psychotherapeutic treatment. Conclusions: Our arguments support the tendency that can be observed in health care in recent years towards more active patient involvement across different health-care domains, but also in clinical research. This article offers an ethical perspective on the question what defines a 'good psychotherapy', which, hopefully, will help to leave behind some of the ongoing psychotherapy debates and move the field forward.
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The practice of Routine Outcome Monitoring (ROM) has grown in popularity and become a fixture in feedback-supported clinical practice and research. However, if the interpretation of an ROM measure changes over time, treatment outcome scores may be inaccurate and produce erroneous or misguided interpretations of client progress and therapist efficacy. The current study examined whether factorial invariance held when using the Behavioral Health Measure (BHM-20) longitudinally in a clinical sample (n = 12,467). Using multidimensional item response theory (MIRT) based models for the investigation of the BHM-20 factor structure, at a single time point and then longitudinally. Based on the original factor structure of the BHM-20 a unidimensional model, a three-factor orthogonal model, and a three-factor correlated model were fit to the data, indicating poor model fit with the proposed three-factor or unidimensional models. Next, using EFA and subsequent MIRT procedures, a new four-factor (General Distress, Life Functioning, Anxiety, and Alcohol/Drug Use) model was proposed with improved model-fit statistics. Finally, when testing the longitudinal invariance of the BHM-17 over 10 sessions of treatment, it was found to be fully consistent. The current study proposes the use of a 17-item, four-factor model for a new understanding of the BHM-17. Implications for use in ROM and limitations are discussed.
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This book first appeared in 1970 and has gone into two further editions, one in 1975 and this one in 1985. Yalom is also the author of Existential Psychotherapy (1980), In-patient Group Psychotherapy (1983), the co-author with Lieberman of Encounter Groups: First Facts (1973) and with Elkin of Every Day Gets a Little Closer: A Twice-Told Therapy (1974) (which recounts the course of therapy from the patient's and the therapist's viewpoint). The present book is the central work of the set and seems to me the most substantial. It is also one of the most readable of his works because of its straightforward style and the liberal use of clinical examples.
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From the beginning, psychoanalysis, and the many psychotherapeutic treatments based on it, have shown an odd and very curious lack of interest in outcome research. When a new method of treatment is introduced, one would have imagined that its relative success or failure in curing the disease for the treatment of which it has been introduced would be of the utmost interest and importance; psychoanalysis has been a curious exception to this rule. Freud (1922) must bear the responsibility for this lack of interest. This is what he had to say: “Friends of analysis have advised us to counter-balance a collection of failures by drawing up a statistical enumeration of our successes. I have not taken up this suggestion either. I brought forward the argument that statistics would not be valuable if the units collated were not alike and the cases which had been treated were in fact not equivalent in many respects. Further, the period of time that could be reviewed was short for one to be able to judge of the permanence of the cures; and of many cases it would be impossible to give any account.
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A large-scale study of the effectiveness of psychotherapeutic methods for the treatment of posttraumatic stress disorders was conducted. The sample consisted of 112 persons suffering from serious disorders resulting from traumatic events (bereavement, acts of violence, and traffic accidents) that had taken place not more than 5 years before. Trauma desensitization, hypnotherapy, and psychodynamic therapy were tested for their effectiveness in comparison with a waiting-list control group. The results indicated that treated cases were significantly lower in trauma-related symptoms than the control group. (C) 1989 by the American Psychological Association