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The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work Review - The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work
Second Edition
by Bruce E. Wampold and Zac E. Imel
Routledge, 2015
Review by Kamuran Elbeyoğlu
Nov 3rd 2015 (Volume 19, Issue 45)

The Great Psychotherapy Debate, as the sub title of the book The Evidence for What Makes Psychotherapy Work indicates, is about how exactly psychotherapy works and what research tells us about different types of treatment, including psychiatric drugs from an historical and anthropological point of view. So, the debate is about what makes psychotherapy works, best characterized by a debate between proponents of evidence-based treatments, namely medical model and proponents of common factors, namely contextual model. The first edition of this book was a seminal publication that helped to organize enormous literature in psychotherapy research regarding the effects of psychotherapy. In the first edition Wampold challenged the long-held belief that psychotherapy can best be understood from a medical model and by using a balanced and carefully selected set of studies, he presented a radical new approach, namely the contextual model, to understanding why psychotherapy works. This second addition updates this work by bringing together the wealth of research examining important issues pertaining to treatment effects since the publication of the first edition and by providing an accessible summary of what we know and what needs to be examined.

         The main point Wampold emphasizes is that the practice of psychotherapy and counseling is dedicated to helping individuals lead happier, more productive, and satisfying lives by helping to relieve the distress that motivated them to seek help. A purposeful collaborative relationship between a therapist and the patient, which Wampold calls a therapeutic alliance, is one of the   common elements of effective therapies. He believes that psychotherapy as an effective healing practice needs to be promoted by professional organizations and therapists, instead of just prescribing the pill and expect the patient go on with his/her life. The contextual model, which in the first edition of The Great Psychotherapy Debate he presents as a compelling alternative to traditional research on psychotherapy, which tends to focus on identifying the most effective treatment for particular disorders through emphasizing the specific ingredients of the treatment, is instead derived from a scientific understanding of how humans heal in a social context and focuses on common factors such as alliance, empathy and expectations.  

         In this book, a critical examination of the progress in psychotherapy is undertaken with attention to the hidden, forgotten and ignored factors, as well as to the current practices, policies and research. The first chapter of the book titled History of Medicine, Methods, and Psychotherapy is intended to give a brief history of medicine and psychotherapy so that certain consequences from history are fully understood and that the current debate is put into a proper perspective before the evidence for the contextual model is presented in the following chapters.

The Contextual Model with the expansions based on social science research since it was first proposed in the first edition of The Great Psychotherapy Debate is presented in the second chapter. In this chapter, Wampold reviews alternatives to understanding psychotherapy from a specific theoretical orientation but focus primarily on such a model, the Contextual Model, which takes psychotherapy as a socially situated healing practice. The chapter ends with the proposal of the Contextual Model that the real relationship, expectations and specific ingredients are the three pathways that create change in psychotherapy.

The following chapter is the presentation of the evidence to be considered and the discussion of the conjectures of the Medical Model and the Contextual Model by adopting a reconstruction of science perspective of Lakatos. After concluding that the conjectures of the Medical Model and the Contextual Model predict very different outcomes of various psychotherapy investigations in Chapter 3, Chapters 4 and 5 examines the evidence for absolute efficacy and relative efficacy, respectively.

Chapter 4 presents the benefits of psychotherapy established by meta-analysis and concludes that the history of the investigations of psychotherapy efficacy establishes meta-analysis as an objective and useful way to aggregate studies addressing the same hypothesis. In the next chapter the evidence related to the relative efficacy of various psychotherapies is explored. Drawing upon the Dodo Bird effect referring to uniform efficacy of psychotherapies, proposed by Rosenberg, the chapter concludes that since the Dodo Bird conjecture has survived many tests, uniform efficacy of treatments represents the first evidence that the medical Model cannot explain the empirical findings in psychotherapy research.

The following chapter investigates an ignored but critical factor in the efficacy of psychotherapy, namely therapist effects. As the reviewed evidence supports some therapists achieve better outcomes than others despite the treatment provided, an important question arises: “what are the characteristics and actions of an effective therapist?” This question is the topic of the following two chapters. Chapter 7 considers the general effects by meeting challenges and anticipating additional evidence for the Contextual Model. In this chapter, authors focus directly on the working alliance first of all because the alliance is a central construct in the Contextual Model and also for some other reasons, such that the alliance has long been theorized to be a pan-theoretical construct that is critical to the success of all treatments, that there is more research on the alliance than on any other factor and that the alliance as a therapeutic factor has come under much scrutiny from adherents of the Medical Model, on a number of quite legitimate grounds.

After examining the evidence for general effects, in the Chapter 8, they examine the evidence for specific ingredients. They ask whether the purported ingredients of an effective treatment responsible for the benefits of the treatment, and after reviewing the research, conclude that there is no compelling evidence that the specific ingredients of any psychotherapy or specific ingredients in general are critical to producing the benefits of psychotherapy.

The last chapter titled as Beyond The Debate is about the implications of the research synthesis for theory, policy and practice. They come to the conclusion that the Contextual Model is based on scientific grounds and in the light of the future research, both models have the opportunity to show their scientific worth as well as the worth of the implications for the policy, practice and training.

This new edition of The Great Psychotherapy Debate, with its inclusion of history of healing practices, medicine and psychotherapy and a thoughtful review and summary of the research in the area on common factors such as the alliance, expectations and empathy, updates the work that started in the first edition greatly, and extends the discussion on the effects of psychotherapy along different pathways, offering important implications for the future of the field. Because the scope of the book is broad enough to cover both theoretical and historical issues and also thorough, sophisticated empirical analyses, it is of use for both a psychotherapist in the field or a skilled psychotherapy researcher as well as an advanced psychology or counseling student.  I heartily recommend this book for any graduate course on psychotherapy and also for anyone who wants to conduct psychotherapy research.


© 2015 Kamuran Elbeyoğlu


Prof. Dr. Kamuran Elbeyoğlu, Toros University, Psychology Department, Mersin, Turkey


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