Brave new world: Mental health services 25 years since Dodo and 25 years in the future

The Old World

In the 1990s, claims for the superiority of a particular treatment disturbed me. I was trained in mathematics and the sciences, so my perspective on psychotherapy was saturated by the scientific method—clearly, the claims for superiority were more advocacy than science. Additionally, my personal experience with and preferences for psychotherapy were not oriented toward symptom focused methods. Finally, there is part of my personality that made it difficult to accept a dictate from powerful figures, to be quite frank (which, I am sure will not surprise anyone who knows me). To examine claims of superiority, my students and I undertook a meta-analytic examination of comparisons of psychotherapies intended to be therapeutic (Wampold et al., 1997). Not one fragment of evidence for treatment differences emerged.

Misconceptions about the meta-analysis abound. Not once have I claimed that this meta-analysis proves that the common factors are responsible for the benefits of psychotherapy. As Cuijpers (in press) noted, the equivalence of treatments does not infer that the so called common factors¹ are the mechanisms of change, although it suggests that this may well be the case. Based on research in various areas of psychotherapy (e.g., relationship factors, alliance, and therapist effects), placebo effects, medicine, and social psychology, there is extensive support for the conjecture that evolved human characteristics are involved in social healing, of which psychotherapy is a well-developed example (Wampold, 2021; Wampold & Imel, 2015). However, a vital component of any viable intervention is a coherent, cogent (within the cultural context), and believable treatment administered by a competent and persuasive clinician. Although I agree enthusiastically with Westra (in press) about the necessity to improve relationship skills, particularly in interpersonally challenging situations, the focus on the patient’s problems and the patient’s efforts toward progress towards their goals, within a believable treatment context, is essential as well. Simply relating to a patient without a coherent treatment and work toward goals is as deficient as delivering a treatment, say following a treatment manual, without the necessary relational skills. Why is the field so resistant to the notion that a believable treatment delivered by an interpersonally skilled clinician is essential—both, not either or. Finally, I am skeptical of improving services by implementing purportedly superior treatments in a system of care, based on a randomized clinical trial, because (a) the results often defy reasonable explanations (no differences at six months but differences at 12 months; Barkham, in press), (b) implementing results from clinical trials in other contexts is fraught with difficulty (Deaton & Cartwright, 2018), (c) psychotherapy trials rarely if ever are replicated (Frost et al., 2020), (d) differences among therapists, due to their clinical skills, are more important than differences among treatments, even if a treatment is demonstrably (but marginally) better (Wampold & Imel, 2015), and (e) such implementation reduces therapist and patient preferences and leads to therapist discouragement. The designation of the RCT as the gold standard of psychotherapy research has set us back decades—to wit, identify one clinically actionable conclusion from RCTs, which by the way have cost hundreds of million of dollars.

But I have said all this before and it is time to look to the future.

The Brave New World

I found the three commentaries on the dodo bird meta-analysis (viz., Barkham, in press; Cuijpers, in press; Westra, in press) encouraging because they challenge the status quo and propose systemic changes in mental health services: Barkham by using precision mental health based on big data, Westra by training and momentary feedback, and Cuijpers by modifying and developing cost-effective treatments for low- and middle-income countries. But there is so much more to do.

Over the years, as I and others have discussed psychotherapy innovations, we have been met with many who believe that psychotherapy must be delivered for 50 minutes a week, face-to-face in a clinic interview room, for a prolonged period; to improve a therapist learns from discussing cases and receiving supervision from a more experienced therapist. We now conduct most psychotherapy electronically, which combined with mental health apps (there are more than 10,000), internet guided therapies, precision mental health, natural language processing of therapy, electronic assisted deliberate practice of therapy skills, text messaging, and many other mental health software solutions, there is no turning back. Let’s not succumb to the Carl Bridenbaugh (former president of the American Historical Association) effect; in his address to the association, mentioned the “great mutation” of society and noted that “we are now suffering something like historical amnesia” due to “the ugly yellow Kodak boxes and the transistor radio” (as cited in Gleick, 2011). Talk therapy has been around for about 150 years and is a cultural healing practice—there is no sacrosanct aspect of it that must survive.

Yet, we have to be careful about the way forward. I offer a few principles:

• Theory. As Kurt Lewin said, “Nothing as practical as a good theory.” We know much about how people suffering from mental distress improve and change. This knowledge should guide innovations.

• Social healing. Humans have evolved to heal in a social context. It is evident that alliance exists in many healing interactions other than a face-to-face interactions and needs to be considered in all forms of healing (Wampold & Flückiger, 2023).

• Reverence for evidence. More than ever, we will have to produce evidence that innovations lead to improvement. And as a corollary, let’s not waste any more time and effort on arguments about whose treatment is more effective.

Onwards.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Notes

1 A much preferred term is therapeutic factors, as these are factors in all healing practices, including psychotherapy, medicine, and complementary and alternative treatments, as well as, dare I say, culturally indigenous treatments (thank you, Jerome Frank).