Is There Such a Thing as the “Best Psychotherapy”?
If you have ever looked for a psychotherapist, you may have encountered the phrase “evidence-based therapy.”
It sounds reassuring. We naturally want to know that the therapy we are choosing has been scientifically tested and shown to work.
And research is important. Psychotherapy should not be exempt from scientific scrutiny simply because it deals with something as complex and subjective as human experience.
But there is an interesting question behind the phrase evidence-based psychotherapy:
Does the evidence actually tell us that there is one best kind of psychotherapy?
The answer is more complicated than it might first appear.
What does “evidence-based” actually mean?
Evidence-based practice is sometimes presented as though it means: choose the therapy with the strongest scientific evidence.
But that is not quite what the term means.
The American Psychological Association defines evidence-based practice as the integration of the best available research with clinical expertise, considering the characteristics, culture and preferences of the person receiving therapy.
That is a considerably broader idea.
Research evidence is one part of the picture. Clinical judgement is another. And the person sitting in front of the therapist is another.
This distinction matters because a treatment that has demonstrated effectiveness for a particular condition in research does not automatically mean that it is the best treatment for every individual experiencing that condition.
People are not diagnoses alone.
The appeal of the “best therapy”…
There is an understandable desire to rank psychotherapies.
Is CBT better than psychoanalysis?Is ACT better than CBT?Is EMDR better than talking therapy?Is one approach more scientific than another?
Research sometimes does identify differences between treatments for particular problems. There are psychological treatments with substantial evidence supporting their effectiveness for specific conditions.
But the leap from “this treatment has evidence for this problem” to “this is the best psychotherapy” is much larger.
Psychotherapy research generally compares groups of people.
Psychotherapy itself happens between two individuals.
This is not the same thing.
The person matters.
Imagine two people who both come to therapy with anxiety.
One wants practical strategies and finds it reassuring to understand exactly what they are supposed to do between sessions.
Another wants to understand why anxiety has become such a persistent part of their life. They may need space to explore relationships, earlier experiences, patterns of avoidance, conflicts, or questions about identity and meaning.
Both may have the same diagnostic label, according to the Diagnostic and Statistical Manual (DSM…) that the insurance companies use to decide how many sessions you (should) need to get better.
But the two patients are NOT the same people, and their anxiety - while fitting in with the same diagnostic category, is NOT the same, nor is it there for the same reasons.
Their histories are different. Their personalities are different. Their circumstances are different. Their expectations of therapy are different. Their relationships with their therapists will be different.
The APA's guidelines specifically recognize that psychological treatment needs to take into account factors such as the person's problems, strengths, personality, sociocultural context, readiness for change, values and treatment preferences.
In other words, good psychotherapy cannot simply be reduced to matching a diagnosis with a protocol.
What about the therapeutic relationship?
This raises another important question.
If different forms of psychotherapy can produce positive outcomes, what exactly is producing the change?
Is it the particular technique?
Is it what all effective therapies have in common?
Or is it some combination of the two?
There has been considerable research into what are often called common factors: elements that may exist across different forms of psychotherapy, including the therapeutic relationship, collaboration, empathy, expectations and the creation of a meaningful framework for understanding and addressing problems.
But even here, the evidence is more complicated than either side of the debate sometimes suggests. A major review concluded that research has not yet established whether psychotherapy works primarily through common factors, therapy-specific factors, or both.
This does not mean that therapeutic techniques don't matter.
It means that psychotherapy is probably not as simple as finding the one technique that “works.”
The therapist is part of the treatment.
There is another variable that is difficult to eliminate from psychotherapy research:
the therapist.
Two therapists can be trained in exactly the same approach and work very differently.
Their ability to listen, understand, formulate a problem, establish a therapeutic relationship, recognize when something isn't working and adapt their approach can all influence the experience of therapy.
This is one reason the APA includes clinical expertise as part of evidence-based practice rather than treating research findings as something that can simply be applied mechanically.
And there is an interesting complication within psychotherapy research itself.
Researchers are human beings too.
They may have spent years developing, studying and promoting a particular therapeutic approach. Research has found an association between researchers' allegiance to particular treatments and treatment outcomes in psychotherapy research. A review of 30 meta-analyses found a moderate association between researcher allegiance and reported treatment effects.
This doesn't mean that psychotherapy research is unreliable.
It means that research itself needs to be examined critically.
And then there is the question of real life…
Much psychotherapy research takes place under carefully defined conditions. This is useful because researchers need to know what they are testing.
But ordinary therapy is rarely so tidy.
A person may arrive with anxiety, relationship difficulties, grief, childhood experiences, problems at work, questions about identity and a sleep problem—all at the same time.
Life doesn't necessarily divide itself into neat diagnostic categories.
And therapy does not always follow a predetermined sequence.
Sometimes what initially appears to be the problem turns out not to be the deepest problem at all.
Sometimes a technique that should theoretically be helpful doesn't suit the person.
Sometimes a person isn't ready for what the therapist initially thinks would be useful.
And sometimes the most important development in therapy is something that would be very difficult to capture in a treatment manual.
So, does evidence matter?
Absolutely.
The answer isn't to reject evidence or scientific research in favor of intuition.
Quite the opposite.
Therapists have a responsibility to understand the research relevant to their work, to recognize the limits of their knowledge, and to remain open to evidence that challenges their assumptions.
But evidence-based practice is not the same thing as evidence-only practice.
The research tells us what tends to help people with particular problems under particular circumstances.
Clinical experience helps us understand how to apply that knowledge.
And the person in therapy tells us something neither a clinical trial nor a treatment manual can tell us on its own: what it is like to be this particular person, living this particular life, at this particular moment.
That is why the question I would ask is not necessarily:
“Which psychotherapy is the best?”
but rather:
“What kind of therapy, with what kind of therapist, is most likely to be helpful for this person?”
That is a more complicated question.
But perhaps complexity is not something we should be trying to eliminate from psychotherapy.
After all, people are complicated.
And perhaps the best psychotherapy is not a single method at all, but a thoughtful meeting between evidence, clinical knowledge, therapeutic relationship and the unique person sitting in the room.
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