Table Of ContentThe Great Psychotherapy Debate
The second edition of T he Great Psychotherapy Debate has been updated and revised
to expand the presentation of the Contextual Model, which is derived from a
scientifi c understanding of how humans heal in a social context and explains
fi ndings from a vast array of psychotherapy studies. This model provides a
compelling alternative to traditional research on psychotherapy, which tends to
focus on identifying the most effective treatment for particular disorders through
emphasizing the specifi c ingredients of treatment. The new edition also includes
a history of healing practices, medicine, and psychotherapy; an examination of
therapist effects; and a thorough review of the research on common factors such
as the alliance, expectations, and empathy.
Bruce E. Wampold , PhD, ABPP, is the Patricia L. Wolleat Professor of Coun-
seling Psychology at the University of Wisconsin–Madison and director of the
Research Institute at Modum Bad Psychiatric Center in Vikersund, Norway.
Zac E. Imel , PhD, is an assistant professor with the counseling psychology
program in the department of educational psychology and an adjunct assistant
professor in the Department of Psychiatry at the University of Utah.
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The Great Psychotherapy
Debate
The Evidence for What Makes
Psychotherapy Work
Second Edition
Bruce E. Wampold and
Zac E. Imel
Second edition published 2015
by Routledge
711 Third Avenue, New York, NY 10017
and by Routledge
27 Church Road, Hove, East Sussex BN3 2FA
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2015 Bruce E. Wampold and Zac E. Imel
The right of Bruce E. Wampold and Zac E. Imel to be identifi ed as authors
of this work has been asserted by them in accordance with sections 77
and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced
or utilised in any form or by any electronic, mechanical, or other means,
now known or hereafter invented, including photocopying and recording,
or in any information storage or retrieval system, without permission in
writing from the publishers.
Trademark notice : Product or corporate names may be trademarks
or registered trademarks, and are used only for identifi cation and
explanation without intent to infringe.
First edition published by Routledge 2001
Library of Congress Cataloging-in-Publication Data
Wampold, Bruce E., 1948–
The great psychotherapy debate : the evidence for what makes
psychotherapy work / by Bruce E. Wampold and Zac E. Imel. —
Second edition.
pages cm
Includes bibliographical references and index.
1. Psychotherapy—Philosophy. 2. Psychotherapy—Evaluation.
I. Imel, Zac E. II. Title.
RC437.5.W35 2015
616.89′14—dc23
2014032867
ISBN: 978-0-8058-5708-5 (hbk)
ISBN: 978-0-8058-5709-2 (pbk)
ISBN: 978-0-203-58201-5 (ebk)
Typeset in Baskerville
by Apex CoVantage, LLC
To all of my collaborators, personal and professional, many
of whom have made sacrifi ces so that this revision could be
completed. BEW
To KT, Jiajia, and Lulu. ZEI
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Contents
Preface viii
1 History of Medicine, Methods, and Psychotherapy:
Progress and Omissions 1
2 The Contextual Model: Psychotherapy as a Socially
Situated Healing Practice 37
3 Contextual Model Versus Medical Model: Choosing
a Progressive Research Programme 62
4 Absolute Effi cacy: The Benefi ts of Psychotherapy
Established by Meta-Analysis 82
5 Relative Effi cacy: The Dodo Bird Still Gets It 114
6 Therapist Effects: An Ignored but Critical Factor 158
7 General Effects: Surviving Challenges and Anticipating
Additional Evidence 178
8 Specifi c Effects: Where Are They? 213
9 Beyond the Debate: Implications of the Research
Synthesis for Theory, Policy, and Practice 255
References 279
Index 317
Preface
W hen one publishes a book with the word debate in the title, one must be pre-
pared for rebuttals. In science, rebuttals are best presented as evidence. In the
13 years since the fi rst edition, there have been many arguments about what
makes psychotherapy work, best characterized by a debate between proponents
of evidence-based treatments and proponents of common factors. This debate
often mischaracterizes one side or the other, with more than a few instances
when rhetorical accusations have predominated, rather than evidence.
R hetoric does not keep me up at night but evidence surely does. And since
the fi rst edition, there have been many reasons for sleepless nights. As Zac
and I discuss in this volume, psychotherapy evidence has proliferated since the
fi rst edition. The number of psychotherapy clinical trials and meta-analyses
of these trials has increased exponentially. There is more evidence now for the
effectiveness of psychotherapy than ever before. Would that evidence trend
toward showing the scientifi c folly of the Contextual Model that I proposed
in 2001? If so, then the Contextual Model would fall on the scrap heap of
perfectly rational, but empirically unsupported, theories, including chemical
theories of fermentation (spontaneous generation), light propagation through
aether, and a static universe (Einstein’s Universe). Yet, the research conducted
in the last decade and a half has not produced evidence that seriously threatens
the Contextual Model—indeed, the evidence for the Contextual Model is an
order of magnitude stronger than it was in 2001.
I n the preface to the fi rst edition I spoke about the meaning of psychother-
apy for me personally and dedicated the book in part to my therapist. Sadly,
some have used this intimate story to say that my work is biased and should
not be trusted. So, let me be clear about this—as is true of all humans, I do
indeed have biases. However, one hallmark of science is that we intentionally
put our biases aside and attend rationally to evidence. Moreover, the scientifi c
endeavor is a correcting system in that evidence in the end will prevail and
theories will be abandoned, despite their ability to attract adherents, should the
evidence be suffi ciently compelling. As with all theories, the current iteration
of the Contextual Model will be modifi ed as anomalies are detected—in the
coming decades, evidence will likely emerge that both clarifi es and complicates
Preface ix
components of the model. In this process, my allegiance is to the evidence and
there is no disgrace in having one’s theory ultimately to be found in the same
dustbin as Einstein’s Static Universe.
This edition of The Great Psychotherapy Debate differs from the fi rst edition in
several ways. Of course, the research corpus is updated and the various chap-
ters refl ect the latest evidence. The fi rst chapter now presents a brief history
of medicine and psychotherapy to put the current debate into proper perspec-
tive. In 2001, the Contextual Model I proposed was just emerging from the
work of Jerome Frank. During the last decade, the model has expanded based
on social science research—the expanded model is presented in C hapter 2.
As in the previous edition, there is a chapter ( Chapter 3 ) that presents what
evidence is to be considered and then discusses the conjectures of the Medical
Model and the Contextual Model. As in the fi rst edition, there are chapters
that examine the evidence for absolute effi cacy (C hapter 4) , relative effi cacy
(C hapter 5) , and therapists’ effects (C hapter 6) . In the fi rst edition, evidence
related to general effects was limited to a discussion of the therapeutic alliance.
We have expanded this section to also include how placebos induce powerful
expectations, as well as several other therapeutic factors hypothesized to be
powerful in the Contextual Model (C hapter 7) . C hapter 8 reviews the literature
on the importance of specifi c ingredients. C hapter 9 makes conclusions related
to theory, practice, and policy.
B ooks have authors. But authorship refl ects an amalgamation of infl uences.
To a large extent, my work was spawned from discussions with students and
collaborations with colleagues around the world. Zac Imel, from his fi rst days
as my doctoral advisee over a decade ago, has challenged me to think deeply
about the issues discussed in this edition and expand my methodological exper-
tise. He would bring articles and books to me: “You have to read this!” and “We
have to learn new methods to understand this issue,” his restless mind collect-
ing and synthesizing information from a variety of spheres. This edition has
continued our intellectual collaboration, mutually stimulating and rewarding.
BEW, Madison, Wisconsin, April 1, 2014
Quite unintentionally, my psychology training began in small groups that
were a part of church youth camps in the Red Rock Canyons of Oklahoma. I
observed the work of talented group leaders who worked to replace emptiness
and shame with acceptance and support. While many of my peers were taken
with spiritual explanations for these experiences, in me they awoke an apprecia-
tion for open and emotionally charged relationships and provided an enduring
template that continues to guide my relationships and inform my clinical work.
The intervention we discuss in this book is still mostly a human conversation—
perhaps the ultimate in low technology. Something in the core of human connec-
tion and interaction has the power to heal. Ironically, the unavoidable complexity
of unstructured, emotional dialogue poses an immense challenge to scientists
who wish to know why it is that conversations with certain characteristics lead to
