The Specificity Myth: The Fallacious Premise of Mental Health Treatment

By: Jerold D. Bozarth, Ph.D.

 

Source: Bozarth, J. (August, 2000). The Specificity Myth: The Fallacious Premise of Mental Health Treatment. Paper presentation at the American Psychological Association, Washington, D. C. Posted by permission of Dr. Bozarth. Copyright by Dr. Bozarth.

This paper contends that mental health treatment in the United States is founded upon a fallacious premise; that is, the premise that there are specific treatments for specific dysfunction. I label this premise, “The Specificity Myth”. This myth has been perpetuated from the medical model and from behavioral treatment models for mental dysfunction. It is found in extreme form in the attempts to identify Empirically Validated Treatments (EVT) (Recently termed Empirically Supported Treatments (EST)).

The argumentis not new from the standpoint of fundamental views of the nature of humanbeings. O’Hara (1993) summarizes the two most prominent views of humannature as the deterministic view and the view of humans as beings in theprocess of actualization. She identifies the determinsitic view as suggestingthat “…the only valid knowledge is scientific knowledge, hence, humanlife is predictable, explainable and controllable” (p. 9). The view ofthe actualizing human being suggests “…a process by which the naturalinner being is set free from the stunting effect of civilization to realizeitself and to actualize its highest potentials” (p. 8). The deterministicview currently dominates mental health treatment with the illusion of scientificverification. This view blends with the medical model for physical illnessthat has dominated mental health treatment propelling the assumption thatappropriate diagnosis is related to viable treatment.

This paper reviewsthe credibility of diagnosis, the pattern of psychotherapy outcome research,the conclusion of five decades of psychotherapy outcome research, and severalintrinsic flaws in the reported evidence for Empirically Supported Treatment.

Diagnosis

Psychiatric diagnosisand empirically validated treatment are predicated upon the same assumption.Both are based upon classification with the claim that classification iscentral to science. Hence, both are implicitly linked to science with theimplication that the foundation and process of this conclusion does notneed to be examined. That is, the logic is that the assumptions are integrallyrelated to science and not open to critique.

Diagnosis involvestwo assumptions. First, it is assumed that there is a relationship amongcertain phenomena (discovered by researchers) from which the concept ofa diagnostic label can be determined. Second, it is assumed that thereis a binding of the clusters identified by researchers. The validity ofboth of these assumptions is sorely lacking in relation to psychiatricdiagnoses. For example, it was clear from my (Bozarth, 1999) personal observationsin the 1950’s and my personal studies in the 1960’s that a particular diagnosisor even psychological description was more related to the diagnosticianor author of the descriptive reports than to the characteristics of the”patients”. It became common knowledge among hospital personnel that thediagnosis of “schizophrenia” in the 1950’s was a catch all for those whodid not fit other diagnostic categories. Boyle (1990) presents a compendiumof arguments that schizophrenia is a “scientific delusion”. Boyle (1999)states that “…there is no evidence whatsoever that the original introductionof the concept of schizophrenia was accompanied by the observation of ameaningful relationship amongst the many behaviors and experiences fromwhich the concept was inferred” (p. 80). Statistical studies of groupsdiagnosed as schizophrenia show no evidence of the symptoms clusteringtogether in a meaningful way (Bentall, 1990; Slade & Cooper, 1979).Similar lack of evidence of other diagnostic concepts has been found instudies of depression (Hallett, 1990; Wiener, 1989; panic disorder (Hallam,1989); agoraphobia (Hallam, 1983); borderline personality disorder (Kutchins& Kirk, 1997); self-defeating or masochistic personality disorder (Caplan& Gans, 1991). Boyle (1999) presents an extensive discussion of thesecritical points; i.e., the previous “discovery” of patterns by researchersand the existence of underlying processes, which she contends has beenseriously questioned in relation to psychiatric diagnoses. Boyle concludesthat:

The assumptionsbehind psychiatric classification are extremely problematic, which is hardlysurprising as they were developed by medicine to suit bodily processesnot people’s behaviour and experience. Non-diagnostic approaches demanda very different set of assumptions, which in turn demand a different setof social and therapeutic responses (p. 88).

These problematicassumptions are the basis of the current mental health treatment system.The problems with these assumptions are virtually ignored in the developmentof the diagnostic manuals. Rather, the attention is directed to the benefitsof the manual for the purpose of providing “…clear descriptions ofdiagnostic categories…” (American Psychiatric Association, p. xxvii).Further, these diagnostic categories are to enable investigators “…to diagnose, communicate about, study, and treat people with variousmental disorders” (p. xxvii). This is about it! There is noticeable absenceof designated treatment for diagnoses. When we come to the basic purposeof diagnosis; that is, determination of the most appropriate treatmentfor a particular dysfunction, there is notorious lack of recommendations.Why is this? Is it that the coalitions of therapeutic approaches couldnot agree upon uniform treatment for any particular diagnosis? Is it thatthe social zeitgeist is much of the determinant of psychiatric diagnoses?Is it that the adherence of the model to find specificity simply ignoresfindings, which are not compatible to the method? Is the system creatingnew mental illnesses within the facade that such illnesses are being scientificallydiscovered? The classic example of the influence of societal views on thedevelopment of diagnosis was the diagnosis of homosexuality in the earlierdiagnostic manuals. Homosexuality was once a diagnostic category that requiredtreatment for deviant pathology. “Gay and Lesbian Issues” is now a divisionof the American Psychological Association. Perhaps, we can hope that thecurrent diagnostic categories of DMS-IV is as valid. It is a remarkablyefficient way to eliminate pathology.

Pattern of PsychotherapyOutcome Research

Another remarkabletwist of scientific method research in psychotherapy outcome studies isthe shift towards specificity research. The drive for more rigor, moreprecision and more focus on specific operational variables has resultedin failure to build on the outcome findings of the last four decades. Thisis reflected in the reviews reported later. However, the study of patternsof psychotherapy efficacy research by Stubbs and Bozarth (1994) depictsa sobering picture.

In the articledubbed, “The Dodo Bird revisited: A qualitative study of psychotherapyresearch”, five temporal categories characterized the evolution of psychotherapyoutcome research. The title of the investigation picked up on Luborsky,Singer, and Luborsky’s (1975) review of comparative studies of psychotherapywhere they concluded that there was equivalence in the effectiveness ofall therapies. They used the Dodo Bird metaphor from “Alice in Wonderland”where there was a race to help the animals dry off after they had becomewet with Alice’s tears. Since the animals ran in different directions,the race was just stopped. The Dodo bird was asked, “Who has won?” He finallyexclaimed, “Everybody has won, and all must have prizes.” Luborsky et.al. used this statement to convey the idea that all therapies should beconsidered equally effective. The “Dodo Bird” study reveals that commonfactors are likely to be the source of this equivalence. The categoricalthemes discovered by Stubbs and Bozarth were the following:

Category 1: Psychotherapyis no more effective than no psychotherapy (1950’s and 1960’s) (Eysenck,1952; 1966).

Eysenck’s hypothesisthat psychotherapy is no more effective than no psychotherapy stimulatedconsiderable reaction and criticism (Bergin, 1971). Somewhat unheraldedand unrealized, the research on Rogers’ hypothesis of the necessary andsufficient conditions became an important part of the responses to Eysenck.This is elaborated upon in Category 3. Other re-analyses of Eysenck’s dataand other findings refuted this contention. Psychotherapy was generallyfound to be effective. Later studies using meta-analysis confirmed thegeneral effectiveness of psychotherapy.

Category 2: The”core conditions” (empathic understanding, unconditional positive regard,and congruence) are necessary and sufficient for therapeutic personalitychange (1960’s and 1970’s).

The second categoryrevealed that a large number of studies were related directly to Rogers’hypothesis of the “conditions therapy theory” (Barrett-Lennard, 1998).Rogers’ hypothesis was consistently supported (Lambert, DeJulio, and Stein,1978; Truax and Mitchell, 1971) and continued to be supported through thelatter 1970’s and 1980’s (e. g., Orlinsky & Howard, 1986; Patterson,1984) in the face of more equivocal reviews to be noted next. Truax andMitchell (1971) presented fourteen studies (eight of which were individualtherapy) consisting of 992 subjects. They identified 125 specific outcomemeasures favoring the hypothesis (66 of 158 were statistically significant).They report an analysis of the long-term effects of higher and lower levelsof empathy, warmth, and genuineness experienced by the clients of the WisconsinProject with hospitalized psychotics (Truax & Mitchell, 1971, p. 329).Their data over nine years indicates that patients seen by therapists lowon the conditions tended not to get out of the hospital, and that clientsof these same therapists did get out tended to return.

Lambert, Shapiro,and Bergin (1986) concluded in their review of the research that the attitudinalqualities: “seem to make up a significant portion of the effective ingredientsof psychotherapy” (p. 202).

Orlinsky andHoward (1986) concluded their review of the research on the attitudinalconditions by stating that: “generally, 50 to 80 per cent of the substantialnumber of studies in this area were significantly positive, indicatingthat these dimensions were very consistently related to patient outcome”(p. 365).

A series of studiesin Germany orchestrated by Reinhard Tausch and colleagues (1990) as wellas other studies in Europe provide additional strong support for Rogers'(1957) hypothesis of the necessary and sufficient conditions for therapeuticpersonality change (see Bozarth, Zimring, & Tausch, in press).

There were alsostudies that investigated the conditions as secondary variables that supportthis theme. For example, the effects of focused versus broad-spectrum behavioraltherapy with problem drinkers in an effort to control their alcohol consumptionwas studied by Miller, Taylor and West (1980). They collected data on therapistempathy as a secondary inquiry and found that the level of therapist empathywas highly correlated (r =.82) with outcome.

Another exampleof the importance of relationship variables was the more recent study bythe National Institute of Mental Health (NIMH) which was conducted to comparevarious treatments for depression (Blatt, Zuroff, Quinlan & Pilkonis,1996). They compared the effects of the administration of a drug (imipramine),cognitive behavioral therapy, interpersonal therapy and “ward management”which served as a placebo. The placebo effect involved a therapist whospent time talking to patients about ward management. There were no significantdifferences between the effects of the three active treatments. The bestprediction of success at the end of any of the active treatments was whetherthe patient perceived the therapist as empathic at the end of the secondinterview. Drug treatment was significantly more successful if the patientviewed the therapist as empathic after the second interview.

Category 3:Psychotherapy is for better or for worse (early 1960’s).

Therapists whowere higher on the conditions were found to be related to positive outcome,while therapists lower on the conditions were related to client deterioration.As mentioned above, this was a strong argument against Eysenck’s assertionsthat no psychotherapy was as effective as psychotherapy.

Several reviewerspointed to the adverse effects of some therapists. Truax and Carkhuff (1967)concluded their research review with the statement that psychotherapy was”for better or for worse” (p 143). The review by Truax and Mitchell (1971)included a call for attrition in the ranks of “psychonoxious practitioners”while increasing the number of helpful counselors (p. 301). The deleteriouseffects of some therapists was highlighted.

Based upon aseparate research review, Bergin (1971) concluded that the previous fourdecades of the practice of psychotherapy has had an effect that is modestlypositive, adding: “However, the averaged group data on which this conclusionis based obscure the multiplicity of processes occurring in therapy, someof which are now known to be either unproductive or actually harmful” (p.263).

Lambert, Shapiroand Bergin (1986) also found evidence to support the position that psychotherapyis for better or for worse; indicating that some therapists are detrimentalas reflected in outcome data.

It is interestingthat research on this rather dire finding, which suggests that therapistslow on the attitudinal conditions were detrimental to their clients, virtuallydisappeared with the advent of the thrust for “specificity” studies inthe 1980’s and 1990’s.

Category 4: Thecore conditions are necessary but NOT sufficient for therapeutic personalitychange (late 1970’s and early 1980’s).

Reviews duringthe middle 1970’s through the 1980’s included some that offered equivocalconclusions for Rogers’ hypothesis of the necessary and sufficient conditions.Change in the direction of research began in the middle 1970’s parallelingthese equivocal reviews. The conclusions of the equivocal reviews thatwere supported with some critique of the designs were that (1) “more complexrelationships exist among therapists, patients, and techniques” (Parloff,Waskow, & Wolf, 1978, p. 273); and that (2) the conditions have notbeen adequately investigated (Bozarth, 1983; Mitchell, Bozarth, & Krauft,1977 Watson, 1984). Issues that need resolution were cited by Beutler,Crago, and Arismendi (1986) as the need to find “an acceptance of an optimallevel of therapeutic skill, common methods of measurement, and the creationand control of levels of the facilitative skills” (p. 276).

Opinions predicatedupon other theoretical formulations rather than upon design critique includedthe view that the core conditions were “nonspecific” and similar to placeboeffect (Luborsky, Singer, & Luborsky, 1975; Shapiro, 1971); and that”the conditions are neither necessary nor sufficient although it seemsclear that such conditions are facilitative” (Gelso & Carter, 1985,p. 220). For the most part, the data based equivocal reviews pointed tothe need for more extensive examination of the complex phenomena of Rogers’postulates and called for more rigorous methodological investigation.

There was virtuallyNO support for the category of the conditions being necessary but NOTsufficient.There was not one direct study that supported the assertion that the conditionsare not sufficient. Nevertheless, the assertion of these reviews did affect(or perhaps served as a rationalization for) the direction of research.The research shifted from examining the attitudinal conditions to investigating”specificity”. This shift was clearly NOT predicated upon previous researchresults.

Category 5: Thereare specific techniques that are uniquely effective in treating particulardisorders (late 1989’s and 1990’s).

The search forthe effectiveness of techniques and for specificity virtually extinguishedthe published studies on the Rogerian hypothesis of the necessary and sufficientconditions. On the face of it, studies in client-centered therapy and theconditions therapy theory were no longer viable inquiries in the UnitedStates.

After the middle1980’s, the Rogerian (1997) hypothesis was investigated by only a dozenoutcome studies which emphasized therapists’ empathy (Sexton & Whiston,1994). These studies were all positive. They included a study of therapistvariables that found that emotional adjustment, relationship attitudesand empathy were most predictive of effective therapists (Lafferty, Beutler,& Crago, 1989). Positive therapy outcome in several studies was linkedto such constructs as “understanding and involvement” (Gaston & Marmar,1994), “warmth and friendliness” (Gomes-Schwartz, 1978), and similar constructs(Bachelor, 1991; Gaston 1991; Windholtz, & Silbershatz, 1988). Empathywas strongly related to improvement for depressed clients who were beingtreated by cognitive-behavioral therapy (Burns & Nolen-Hoeksema, 1992).Despite the many positive findings it was the equivocal reviews of theresearch on the attitudinal conditions that proved to be part of the rationalefor research directions toward “specificity” of treatment. The focus on”specificity” research replaced inquiry on Rogers’ hypotheses and on commonfactors in general.

Conclusions ofpsychotherapy outcome research

Stubbs and Bozarth(1994) concluded that: “Over four decades, the major thread in psychotherapyefficacy research is the presence of the therapist attitudes hypothesizedby Rogers” (p. 120.). Concomitant to their conclusion of psychotherapyoutcome research, Duncan and Moynihan (1994) independently analyzed psychotherapyoutcome research. Their report titled, “Intentional utilization of theclient’s frame of reference” reviewed outcome research to develop a treatmentmodel. They conclude that the major operational variable that of intentionallyutilizing the client’s frame of reference. This article was associatedwith an explosion of psychological literature that identifies the commonfactors of relationship and client resources as the basis for most psychologicalimprovement (Asay, T. P., & Lambert, M. J., 1999; Duncan, Hubble, &Miller, 1997; Hubble, Duncan, & Miller, 1999; Lambert, 1992; Miller,Duncan, & Hubble, 1997).

From 1987 to1999, the investigations of specificity research have ironically returnedfull cycle to the pervasive influence of the common factors. That is, thereviews of outcome research by various reviewers including the more recentspecificity research reveal that: (1) Effective psychotherapy is predicatedupon the relationship of the therapist and client in combination with theinner and external resources of the client (common factors) (Hubble, Duncan,& Miller, 1999); (2) Type of therapy and technique add little to theeffect of the relationship and client resources if not accompanied by commonfactors (Hubble et. al., 1999); and (3) Relationship variables that aremost often related to effectiveness are the conditions of empathy, genuinenessand unconditional positive regard (Bozarth, 1999; Patterson, 1984; Stubbs& Bozarth, 1994).

The clear messageof five decades of outcome research is that it is the relationship of theclient and therapist in combination with the resources of the client (extratherapeuticvariables) that respectively account for 30% and 40% of the variance insuccessful psychotherapy. Techniques account for 15% of the success variance,comparable to 15% success rate related to placebo effect.

Intrinsic flawsof Empirically Validated Treatment

There are currentlyefforts in the United States and Europe to involve endorsement of specificpsychotherapies by government, professional organizations, and other accreditingbodies. Those treatments to be approved are those which are “empiricallyvalidated”. It is important to remember that the EVT syndrome (Now referredto as the Empirically Supported Treatment or EST by the Task Force of Division12, Clinical Psychology of the American Psychological Association) is foundedupon the belief that there are specific treatments for particular dysfunction(Task Force on Promotion and Dissemination of Psychological Procedures,1995).

The advocateshave already assumed the veracity of their claim. The task is to now toconvince others; especially those who are in positions to influence policies.The postulate of specificity is accelerated through the use of manualsthat delineate specific procedures.

Advocates ofEST believe that this assumption is supported by “efficacious” empiricalresearch. The arguments for EST are primarily seven points. These pointsare that: 1) much is already know about the effectiveness of specific treatmentswith specific dysfunction; 2) patient care will be improved; 3) the researchwill influence policy makers; 4) better training will be fostered; 5) therapyresearch will be encouraged; 5) it will more fair because of the professionalswho have been consulted in developing the criteria; and 7) the projectis intended to encourage guidelines and lists for effective treatmentsthat can be useful to the field. It can be noted that, like the argumentsfor diagnosis, six of the assertions are based upon the assumption thattheir first argument is true. The assertion that “much is already known”is followed by the six assertions that have to do with influence, strategiesand factors other than the validity of the EST stance. The only substantialargument is whether or not there are effective treatments for particulardysfunction. The bold assertion is affirmative (Barlow, 1996; Chambless,1996). The Institute for the Study of Therapeutic Change (Web Page, talkingcure.com, 2000) succinctly responds to this assertion:

Unfortunately,they (the members of the Task Force) are dead wrong when they link therapeuticeffectiveness to so-called empirically validated treatments (EVT”S). Indrawing their conclusions, members of the Task Force of Division 12 haveignored the conclusion of nearly 40 years of sophisticated outcome research(See Psychotherapy (1997, 33(2)); and American Psychologist (1996,51(10)).

With such a differencein views, it behooves us to look a bit further at assumptions and processof the development of EST’s.

The words “efficacy”and “effectiveness” were interchangeable until recent years. The dictionarydefinitions are synonymous Recently, the term “efficacious” has come toidentify the results of “gold standard” studies (Seligman, 1995). Theseare studies which have been traditionally identified as true design studies;that is, studies which are randomized, double-blind and have an adequatenumber of subjects and have adequate controls for therapists as well ashaving appropriate replications of the study. The rationale is that causationcan be more accurately determined with this type of study. Efficaciousstudies are actually rare in the bulk of research in psychotherapy outcome.The following conclusions attend to major flaws of the assumptions andprocess of confirming EST’s:

Conclusion 1:There is considerable variation of the design criteria from the assumptionthat these are “Gold Standard” studies as implied by the advocates. Thequality of the designs is no more rigorous than many of those representingthe previous five decades of research.

It turns outthat the “efficacious” and “gold standard” studies identified by the taskforce are not quite as efficacious as implied. The Task Force, in one publication,identified 36 studies of “Empirically Validated Treatments and another32 studies of “Probably Efficacious Treatments” (Chambless et. al., 1996).The general criteria for acceptance as efficacious studies includes casestudy design experiments with N’s greater than 9. These experiments arepart of the 36 recommended studies. The task force guidelines for the criteriaof EST now defines their “Well Established Treatments” in less than rigorousterminology. (Task Force on promotion and dissemination of psychologicalprocedures, 1995). Rather than referring to true design studies, they referto the need for “At least two GOOD (authors’ emphasis) group design studies…”. Such loose terminology is indicative of the deviation from theiroriginal intention to utilize “efficacious” studies as the criterion.

A thorough critiqueof the empirically validated treatment studies is presented in the journalof Psychotherapy Research (Bohart, O’Hara, & Leitner, 1998).

Conclusion 2:Five decades of research have been disregarded because those studies arenot viewed as appropriately measuring the specific behaviors of the therapistor either because the do not fit the clusters of client dysfunction whichhave been reliably agreed upon, but not validly determined, by those whorecommended the categories for the DSM-IV.

It is somewhatbaffling how the task force conclusions could be reached after examiningpsychotherapy outcome research over the past five decades. It turns outthat the five decades of research have been summarily disregarded for somewhatobscure reasons. The dismissal is, according to Garfield (1996) relatedto the idea that there are now instruments (i.e. training manuals) thatidentify more specific behaviors and standardize the therapy; and to theidea that there are reliable diagnoses (via the DSM-IV) to which treatmentcan be directed. As noted previously, it is interesting that neither theDSM-lll-R or DSM-IV actually recommend treatments for their “reliable”diagnoses. Treatments are now being determined through the EST phenomenon.

A specific exampleof dismissal is the renowned Smith et. al (1980) analysis of 475 studieswhich concludes that psychotherapy of all kinds is generally more effectivethan no treatment. The study is disregarded primarily on the basis thatit pre-dates the Beck et. al. Manual and DSM-III (Garfield, 1996). Thefaux pas of dismissing the 1980 analysis has been raised anew by a meta-analysisin the November, 1997 issue of the Psychological Bulletin (Wampold, et.al.) which re-confirms the Smith et. al. study. Elliott (1997) also re-confirmsthese findings in his summary of meta-analysis.

Conclusion 3:The findings of five decades of psychotherapy outcome research have discoveredthat the client-driven/person-centered paradigm accounts for the majorsuccess variance for clients.

The most cogentconclusions of this research are:

– That thetype of therapy and technique is largely irrelevant in terms of successfuloutcome;

– That thereis little evidence to support the position that there are specific treatmentsfor particular disabilities; and

– That the influenceof treatment models pales in comparison to the personal qualities of theindividual therapist. (Luborsky et al., 1986).

The most clear researchevidence is that effective psychotherapy results from the resources ofthe client and chance factors related to the client (extratherapeutic variables)and from the person to person relationship of the therapist and client.As previously mentioned, Duncan and Moynihan (1994) cite reviews of quantitativeresearch (e. g., Lambert, 1992; Lambert, Shapiro & Bergin, 1986) thatoffer data to develop a model for clinical practice. It bears repeatingthat these reviews conclude that 30% of the outcome success variance isaccounted for by the common factor of the client-counselor relationship,and 40% of the variance is accounted for by extratherapeutic change variables(factors unique to the client and her/his environment). That is, 70% ofthe successful therapy is accounted for by therapist and client variables.Techniques account for only 15% of the success variance and that is similarto the 15% accounted for by placebo effect. Such research findings suggestthe utility of intentionally utilizing the client’s frame of reference,”courting” the client, and going with the client’s direction in therapy.

Conclusion 4:The precise functional practice of specific treatments for a particulardysfunction is questionable.

How does theconcept of EVT relate to efficacious treatment? We asked this questionto a number of therapists. Here is one response:

The questionis: what do you mean by efficacious treatment? The client comes for a panicattack: maybe they have some other things to say; maybe you tell them somethingof what you know about managing anxiety or whatever; but do you inhibittheir talking about related or non-related topics?

Right now I havea woman who has panic after a traffic accident. It turns out that her sisterwho was the closest person to her died suddenly a few years earlier. Shewent to the hospital for a “simple but delicate procedure…”, her leghad to be cut off and three weeks later she was dead. My client was brokenhearted and in shock. This was her primary focus in the session. Now whatdo I do? Do I treat her for the panic attack from the road accident, whichis the reason for the referral. Or listen to her more pressing concernsas she talks about the rest of it? Do I stop her from talking about whatshe expresses as her more basic difficulty?

How can it beso simple?…what is the definition of efficacious? What is withholdingtreatment? How do you know what the problem is, anyway even if you’re intenton fixing it; if you close off the avenue of talking about it before youbegin? The doctor hadn’t even heard about the sister…that is howefficacious he is…

This is justone of maybe five panic attack cases I have right now…all with tailsthat wag the dog.
 
 

The efficacy oftreatment becomes a bit confounded in the real world.

The myth of ESTis further compromised in the violation of the fundamental premise. Theprimary premise is that there are certain procedures that will ameliorateor diminish particular dysfunction. It is so certain that this is the casethat the procedures are identified via treatment manuals. This is prettygood because what it means is that anyone who is reasonably intelligentcan follow the procedures and the result will be positive. In the 1960’s,wedid this with behavior modification procedures that were integrated intohospitals and schools for the mentally retarded and mentally ill. Wardattendants, many with less than high school education, could follow theseprocedures with reported successful results as long as the procedures werefollowed. Many of these procedures are still in the institutions in spiteof serious questions about the validity of the results. But, if it worksas asserted, let’s do it. However, somehow we find that it requires a doctorallevel psychologist to apply the technical manual. Why is this? If the procedureis, in fact, the point of the whole thing, then why do we need the clinicalpsychologist as a treatment phenomenon? We don’t! If the premise of specificity(that there are particular treatments for particular dysfunction) is correct,the specific treatment is the thing. But now we have an intervening variablepresent. That is, we need a competent clinician in case there are clinicaljudgments to be made when the procedure is not working. This means thatwe must be ready to change the procedure at any given moment and that itis deemed by someone to not be working. The procedure, which is the thing,must be open to be tailor made to the particular client. Among other things,the common factors have entered into the realm of the EST’s.

The fact thatfive decades of psychotherapy outcome research has been ignored in thesearch for specificity as highlighted by the EST proposals is further compoundedby the murkiness of “good” research designs which support procedures thatcan not be trusted without the murkiness of clinical judgment.

Summary

Our examinationof the credibility of diagnosis, the pattern of psychotherapy outcome research,the conclusion of five decades of psychotherapy outcome research, and theintrinsic flaws in the reported evidence for Empirically Supported Treatmentsuggest a radical conclusion.

This conclusionis that the foundation of the mental health system in the United Statesis founded upon a myth; that is, the myth that there are specific treatmentsfor particular dysfunction. This conclusion calls for a radical re-structuringof the mental health system to accentuate the variables related to success.These are the common factor variables of therapist/client relationshipand emphasis of client resources and client frame of reference.

Comments by SamEvans:

I do not agreewith the notion that a diagnosis is given for the purpose of classifyingand treating.  I tend to find a diagnosis somewhat helpful when communicatingwith other professionals regarding mutual clients.  I also find thatin this day and age, many people need a diagnosis for no other reason thanto faciliate payment by their insurance company.  If a psychotherapistsubmitted an invoice for payment by an insurance company, and stated thatthe reason for the visit was “problem actualizing” or “stunted personalgrowth”, I doubt if the bean counters at the imsurance company would understand. As our culture is used to looking at a medical model and is comfortablewith this model, using a diagnosis to facilitate communication only makesit easier for the client to receive the help that is needed.  In anideal world where clients did not need insurance, did not have problemswith the legal system, judges, probation, parole, prison, and professionalsdid not need a concise way to sum up their behaviors, perhaps diagnosiswould not be helpful, but for now, I really need it in my practice. I really think that most psychotherapists, who are not academics or interns,really do not  rely on matching a diagnosis to a specific unproventreatment.  There are too many variations of psychotherapy based ona huge number of theoretical orientations and I find that a good therapistrelies upon what has worked the best for him/her and their clients. We are all different in our approaches to psychotherapy, and for each differentapproach we use different tools.  Personally I find empathy, genuineness,and unconditional positive regard the most helpful in a purely therapeuticrelationship, however, there are psychotherapists who provide a host ofservices that cannot be strictly therapeutic in form.  For example,we are often limited in our practice by laws that mandate specific psycho-educationalpresentations that shall not be altered by the presenter.  Certainlaws, such as Family Violence law in Georgia, go into the smallest detailof how the legislature has commanded service providers to present a modelthat was adopted by the state.  So, again, in an ideal world, I thinkDr. Bozarth is on to something, however, we are practicing in a professionalculture that is full of entangling alliances and struggling to survive. We must not only “help” our clients, but we must understand and conductbusiness with corparate entities, politicians, government bureaucrats,and a host of well meaning and not so well meaning people that touch thelives of our clients.  A drastic overhaul of our mental health systemis not practical or possible, however with quality continuing educationfor professionals, small gradual change for the better may be more likely.

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