The Specificity Myth: The Fallacious Premise of Mental

Health Treatment
Jerold D. Bozarth, Ph.D.
Bozarth, J. (August, 2000). Paper presentation at the American
Psychological Association, Washington, D. C.
Posted by Jerold Bozarth and Sam Evans Person-Centered
International
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 argument is not new from the standpoint of fundamental views
of the nature of human beings. OHara (1993) summarizes the two
most prominent views of human nature as the deterministic view
and the view of humans as beings in the process of actualization.
She identifies the determinsitic view as suggesting that " . . . the
only valid knowledge is scientific knowledge, hence, human life is
predictable, explainable and controllable" (p. 9). The view of the
actualizing human being suggests " . . . a process by which the
natural inner being is set free from the stunting effect of civilization
to realize itself and to actualize its highest potentials" (p. 8). The
deterministic view currently dominates mental health treatment
with the illusion of scientific verification. This view blends with the
medical model for physical illness that has dominated mental health
treatment propelling the assumption that appropriate diagnosis is
related to viable treatment.
This paper reviews the credibility of diagnosis, the pattern of
psychotherapy outcome research, the conclusion of five decades of
psychotherapy outcome research, and several intrinsic flaws in the
reported evidence for Empirically Supported Treatment.
Diagnosis
Psychiatric diagnosis and empirically validated treatment are
predicated upon the same assumption. Both are based upon
classification with the claim that classification is central to science.
Hence, both are implicitly linked to science with the implication that
the foundation and process of this conclusion does not need to be

examined. That is, the logic is that the assumptions are integrally
related to science and not open to critique.
Diagnosis involves two assumptions. First, it is assumed that there is
a relationship among certain phenomena (discovered by
researchers) from which the concept of a diagnostic label can be
determined. Second, it is assumed that there is a binding of the
clusters identified by researchers. The validity of both of these
assumptions is sorely lacking in relation to psychiatric diagnoses.
For example, it was clear from my (Bozarth, 1999) personal
observations in the 1950s and my personal studies in the 1960s
that a particular diagnosis or even psychological description was
more related to the diagnostician or author of the descriptive
reports than to the characteristics of the "patients". It became
common knowledge among hospital personnel that the diagnosis of
"schizophrenia" in the 1950s was a catch all for those who did not
fit other diagnostic categories. Boyle (1990) presents a compendium
of arguments that schizophrenia is a "scientific delusion". Boyle
(1999) states that " . . . there is no evidence whatsoever that the
original introduction of the concept of schizophrenia was
accompanied by the observation of a meaningful relationship
amongst the many behaviors and experiences from which the
concept was inferred" (p. 80). Statistical studies of groups diagnosed
as schizophrenia show no evidence of the symptoms clustering
together in a meaningful way (Bentall, 1990; Slade & Cooper, 1979).
Similar lack of evidence of other diagnostic concepts has been found
in studies 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 these critical points; i.e., the previous
"discovery" of patterns by researchers and the existence of
underlying processes, which she contends has been seriously
questioned in relation to psychiatric diagnoses. Boyle concludes
that:
The assumptions behind psychiatric classification are extremely
problematic, which is hardly surprising as they were developed by
medicine to suit bodily processes not peoples behaviour and
experience. Non-diagnostic approaches demand a very different set
of assumptions, which in turn demand a different set of social and
therapeutic responses (p. 88).
These problematic assumptions are the basis of the current mental
health treatment system. The problems with these assumptions are
virtually ignored in the development of the diagnostic manuals.
Rather, the attention is directed to the benefits of the manual for
the purpose of providing " . . . clear descriptions of diagnostic
categories . . ." (American Psychiatric Association, p. xxvii). Further,
2

these diagnostic categories are to enable investigators " . . . to

diagnose, communicate about, study, and treat people with various
mental disorders" (p. xxvii). This is about it! There is noticeable
absence of designated treatment for diagnoses. When we come to
the basic purpose of diagnosis; that is, determination of the most
appropriate treatment for a particular dysfunction, there is notorious
lack of recommendations. Why is this? Is it that the coalitions of
therapeutic approaches could not agree upon uniform treatment for
any particular diagnosis? Is it that the social zeitgeist is much of the
determinant of psychiatric diagnoses? Is it that the adherence of the
model to find specificity simply ignores findings, which are not
compatible to the method? Is the system creating new mental
illnesses within the facade that such illnesses are being scientifically
discovered? The classic example of the influence of societal views
on the development of diagnosis was the diagnosis of
homosexuality in the earlier diagnostic manuals. Homosexuality was
once a diagnostic category that required treatment for deviant
pathology. "Gay and Lesbian Issues" is now a division of the
American Psychological Association. Perhaps, we can hope that the
current diagnostic categories of DMS-IV is as valid. It is a remarkably
efficient way to eliminate pathology.
Pattern of Psychotherapy Outcome Research
Another remarkable twist of scientific method research in
psychotherapy outcome studies is the shift towards specificity
research. The drive for more rigor, more precision and more focus
on specific operational variables has resulted in failure to build on
the outcome findings of the last four decades. This is reflected in the
reviews reported later. However, the study of patterns of
psychotherapy efficacy research by Stubbs and Bozarth (1994)
depicts a sobering picture.
In the article dubbed, "The Dodo Bird revisited: A qualitative study
of psychotherapy research", five temporal categories characterized
the evolution of psychotherapy outcome research. The title of the
investigation picked up on Luborsky, Singer, and Luborskys (1975)
review of comparative studies of psychotherapy where they
concluded that there was equivalence in the effectiveness of all
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 become wet with Alices tears. Since the animals ran
in different directions, the race was just stopped. The Dodo bird was
asked, "Who has won?" He finally exclaimed, "Everybody has won,
and all must have prizes." Luborsky et. al. used this statement to
convey the idea that all therapies should be considered equally
effective. The "Dodo Bird" study reveals that common factors are
likely to be the source of this equivalence. The categorical themes
discovered by Stubbs and Bozarth were the following:
3

Category 1: Psychotherapy is no more effective than

psychotherapy (1950s and 1960s) (Eysenck, 1952; 1966).

no

Eysencks hypothesis that psychotherapy is no more effective than

no psychotherapy stimulated considerable reaction and criticism
(Bergin, 1971). Somewhat unheralded and unrealized, the research
on Rogers hypothesis of the necessary and sufficient conditions
became an important part of the responses to Eysenck. This is
elaborated upon in Category 3. Other re-analyses of Eysencks data
and other findings refuted this contention. Psychotherapy was
generally found to be effective. Later studies using meta-analysis
confirmed the general effectiveness of psychotherapy.
Category 2: The "core conditions" (empathic understanding,
unconditional positive regard, and congruence) are necessary and
sufficient for therapeutic personality change (1960s and 1970s).
The second category revealed 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 the latter
1970s and 1980s (e. g., Orlinsky & Howard, 1986; Patterson, 1984)
in the face of more equivocal reviews to be noted next. Truax and
Mitchell (1971) presented fourteen studies (eight of which were
individual therapy) consisting of 992 subjects. They identified 125
specific outcome measures favoring the hypothesis (66 of 158 were
statistically significant). They report an analysis of the long-term
effects of higher and lower levels of empathy, warmth, and
genuineness experienced by the clients of the Wisconsin Project
with hospitalized psychotics (Truax & Mitchell, 1971, p. 329). Their
data over nine years indicates that patients seen by therapists low
on the conditions tended not to get out of the hospital, and that
clients of these same therapists did get out tended to return.
Lambert, Shapiro, and Bergin (1986) concluded in their review of the
research that the attitudinal qualities: "seem to make up a
significant portion of the effective ingredients of psychotherapy" (p.
202).
Orlinsky and Howard (1986) concluded their review of the research
on the attitudinal conditions by stating that: "generally, 50 to 80 per
cent of the substantial number of studies in this area were
significantly positive, indicating that these dimensions were very
consistently related to patient outcome" (p. 365).
A series of studies in Germany orchestrated by Reinhard Tausch and
colleagues (1990) as well as other studies in Europe provide
4

additional strong support for Rogers (1957) hypothesis of the

necessary and sufficient conditions for therapeutic personality
change (see Bozarth, Zimring, & Tausch, in press).
There were also studies that investigated the conditions as
secondary variables that support this theme. For example, the
effects of focused versus broad-spectrum behavioral therapy with
problem drinkers in an effort to control their alcohol consumption
was studied by Miller, Taylor and West (1980). They collected data
on therapist empathy as a secondary inquiry and found that the
level of therapist empathy was highly correlated (r = .82) with
outcome.
Another example of the importance of relationship variables was the
more recent study by the National Institute of Mental Health (NIMH)
which was conducted to compare various 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 who
spent time talking to patients about ward management. There were
no significant differences between the effects of the three active
treatments. The best prediction of success at the end of any of the
active treatments was whether the patient perceived the therapist
as empathic at the end of the second interview. Drug treatment was
significantly more successful if the patient viewed the therapist as
empathic after the second interview.
Category 3: Psychotherapy is for better or for worse (early 1960s).
Therapists who were 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
Eysencks
assertions
that
no
psychotherapy was as effective as psychotherapy.
Several reviewers pointed 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 deleterious effects of
some therapists was highlighted.
Based upon a separate research review, Bergin (1971) concluded
that the previous four decades of the practice of psychotherapy has
had an effect that is modestly positive, adding: "However, the
averaged group data on which this conclusion is based obscure the

multiplicity of processes occurring in therapy, some of which are

now known to be either unproductive or actually harmful" (p. 263).
Lambert, Shapiro and Bergin (1986) also found evidence to support
the position that psychotherapy is for better or for worse; indicating
that some therapists are detrimental as reflected in outcome data.
It is interesting that research on this rather dire finding, which
suggests that therapists low on the attitudinal conditions were
detrimental to their clients, virtually disappeared with the advent of
the thrust for "specificity" studies in the 1980s and 1990s.
Category 4: The core conditions are necessary but NOT sufficient for
therapeutic personality change (late 1970s and early 1980s).
Reviews during the middle 1970s through the 1980s included some
that offered equivocal conclusions for Rogers hypothesis of the
necessary and sufficient conditions. Change in the direction of
research began in the middle 1970s paralleling these equivocal
reviews. The conclusions of the equivocal reviews that were
supported with some critique of the designs were that (1) "more
complex relationships exist among therapists, patients, and
techniques" (Parloff, Waskow, & Wolf, 1978, p. 273); and that (2) the
conditions have not been 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 optimal level of therapeutic skill,
common methods of measurement, and the creation and control of
levels of the facilitative skills" (p. 276).
Opinions predicated upon other theoretical formulations rather than
upon design critique included the view that the core conditions were
"nonspecific" and similar to placebo effect (Luborsky, Singer, &
Luborsky, 1975; Shapiro, 1971); and that "the conditions are neither
necessary nor sufficient although it seems clear that such conditions
are facilitative" (Gelso & Carter, 1985, p. 220). For the most part,
the data based equivocal reviews pointed to the need for more
extensive examination of the complex phenomena of Rogers
postulates and called for more rigorous methodological
investigation.
There was virtually NO support for the category of the conditions
being necessary but NOT sufficient. There was not one direct study
that supported the assertion that the conditions are 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 research results.
6

Category 5: There are specific techniques that are uniquely effective

in treating particular disorders (late 1989s and 1990s).
The search for the effectiveness of techniques and for specificity
virtually extinguished the published studies on the Rogerian
hypothesis of the necessary and sufficient conditions. On the face of
it, studies in client-centered therapy and the conditions therapy
theory were no longer viable inquiries in the United States.
After the middle 1980s, the Rogerian (1997) hypothesis was
investigated by only a dozen outcome studies which emphasized
therapists empathy (Sexton & Whiston, 1994). These studies were
all positive. They included a study of therapist variables that found
that emotional adjustment, relationship attitudes and empathy were
most predictive of effective therapists (Lafferty, Beutler, & Crago,
1989). Positive therapy outcome in several studies was linked to
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). Empathy was strongly related to improvement
for depressed clients who were being treated by cognitivebehavioral therapy (Burns & Nolen-Hoeksema, 1992). Despite the
many positive findings it was the equivocal reviews of the research
on the attitudinal conditions that proved to be part of the rationale
for research directions toward "specificity" of treatment. The focus
on "specificity" research replaced inquiry on Rogers hypotheses and
on common factors in general.
Conclusions of psychotherapy outcome research
Stubbs and Bozarth (1994) concluded that: "Over four decades, the
major thread in psychotherapy efficacy research is the presence of
the therapist attitudes hypothesized by Rogers" (p. 120.).
Concomitant to their conclusion of psychotherapy outcome
research, Duncan and Moynihan (1994) independently analyzed
psychotherapy outcome research. Their report titled, "Intentional
utilization of the clients frame of reference" reviewed outcome
research to develop a treatment model. They conclude that the
major operational variable that of intentionally utilizing the client's
frame of reference. This article was associated with an explosion of
psychological literature that identifies the common factors of
relationship and client resources as the basis for most psychological
improvement (Asay, T. P., & Lambert, M. J., 1999; Duncan, Hubble, &
Miller, 1997; Hubble, Duncan, & Miller, 1999; Lambert, 1992; Miller,
Duncan, & Hubble, 1997).
From 1987 to 1999, the investigations of specificity research have
ironically returned full cycle to the pervasive influence of the
7

common factors. That is, the reviews of outcome research by

various reviewers including the more recent specificity research
reveal that: (1) Effective psychotherapy is predicated upon the
relationship of the therapist and client in combination with the inner
and external resources of the client (common factors) (Hubble,
Duncan, & Miller, 1999); (2) Type of therapy and technique add little
to the effect of the relationship and client resources if not
accompanied by common factors (Hubble et. al., 1999); and (3)
Relationship variables that are most often related to effectiveness
are the conditions of empathy, genuineness and unconditional
positive regard (Bozarth, 1999; Patterson, 1984; Stubbs & Bozarth,
1994).
The clear message of five decades of outcome research is that it is
the relationship of the client and therapist in combination with the
resources of the client (extratherapeutic variables) that respectively
account for 30% and 40% of the variance in successful
psychotherapy. Techniques account for 15% of the success variance,
comparable to 15% success rate related to placebo effect.
Intrinsic flaws of Empirically Validated Treatment
There are currently efforts in the United States and Europe to
involve endorsement of specific psychotherapies by government,
professional organizations, and other accrediting bodies. Those
treatments to be approved are those which are "empirically
validated". It is important to remember that the EVT syndrome (Now
referred to as the Empirically Supported Treatment or EST by the
Task Force of Division 12, Clinical Psychology of the American
Psychological Association) is founded upon the belief that there are
specific treatments for particular dysfunction (Task Force on
Promotion and Dissemination of Psychological Procedures, 1995).
The advocates have already assumed the veracity of their claim.
The task is to now to convince others; especially those who are in
positions to influence policies. The postulate of specificity is
accelerated through the use of manuals that delineate specific
procedures.
Advocates of EST believe that this assumption is supported by
"efficacious" empirical research. The arguments for EST are
primarily seven points. These points are that: 1) much is already
know about the effectiveness of specific treatments with specific
dysfunction; 2) patient care will be improved; 3) the research will
influence policy makers; 4) better training will be fostered; 5)
therapy research will be encouraged; 5) it will more fair because of
the professionals who have been consulted in developing the
criteria; and 7) the project is intended to encourage guidelines and
lists for effective treatments that can be useful to the field. It can be
8

noted that, like the arguments for diagnosis, six of the assertions
are based upon the assumption that their first argument is true. The
assertion that "much is already known" is followed by the six
assertions that have to do with influence, strategies and factors
other than the validity of the EST stance. The only substantial
argument is whether or not there are effective treatments for
particular dysfunction. 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 therapeutic effectiveness to so-called empirically
validated treatments (EVT"S). In drawing their conclusions,
members of the Task Force of Division 12 have ignored the
conclusion of nearly 40 years of sophisticated outcome research
(See Psychotherapy (1997, 33(2)); and American Psychologist
(1996,51(10)).
With such a difference in views, it behooves us to look a bit further
at assumptions and process of the development of ESTs.
The words "efficacy" and "effectiveness" were interchangeable until
recent years. The dictionary definitions are synonymous Recently,
the term "efficacious" has come to identify the results of "gold
standard" studies (Seligman, 1995). These are studies which have
been traditionally identified as true design studies; that is, studies
which are randomized, double-blind and have an adequate number
of subjects and have adequate controls for therapists as well as
having appropriate replications of the study. The rationale is that
causation can be more accurately determined with this type of
study. Efficacious studies are actually rare in the bulk of research in
psychotherapy outcome. The following conclusions attend to major
flaws of the assumptions and process of confirming ESTs:
Conclusion 1: There is considerable variation of the design
criteria from the assumption that these are "Gold Standard"
studies as implied by the advocates. The quality of the
designs is no more rigorous than many of those
representing the previous five decades of research.
It turns out that the "efficacious" and "gold standard" studies
identified by the task force are not quite as efficacious as implied.
The Task Force, in one publication, identified 36 studies of
"Empirically Validated Treatments and another 32 studies of
"Probably Efficacious Treatments" (Chambless et. al., 1996). The
general criteria for acceptance as efficacious studies includes case
study design experiments with Ns greater than 9. These
experiments are part of the 36 recommended studies. The task
9

force guidelines for the criteria of EST now defines their "Well
Established Treatments" in less than rigorous terminology. (Task
Force on promotion and dissemination of psychological procedures,
1995). Rather than referring to true design studies, they refer to the
need for "At least two GOOD (authors emphasis) group design
studies . . .". Such loose terminology is indicative of the deviation
from their original intention to utilize "efficacious" studies as the
criterion.
A thorough critique of the empirically validated treatment studies is
presented in the journal of Psychotherapy Research (Bohart, OHara,
& Leitner, 1998).
Conclusion 2: Five decades of research have been
disregarded because those studies are not viewed as
appropriately measuring the specific behaviors of the
therapist or either because the do not fit the clusters of
client dysfunction which have been reliably agreed upon,
but not validly determined, by those who recommended the
categories for the DSM-IV.
It is somewhat baffling how the task force conclusions could be
reached after examining psychotherapy outcome research over the
past five decades. It turns out that the five decades of research
have been summarily disregarded for somewhat obscure reasons.
The dismissal is, according to Garfield (1996) related to the idea
that there are now instruments (i.e. training manuals) that identify
more specific behaviors and standardize the therapy; and to the
idea that there are reliable diagnoses (via the DSM-IV) to which
treatment can be directed. As noted previously, it is interesting that
neither the DSM-lll-R or DSM-IV actually recommend treatments for
their "reliable" diagnoses. Treatments are now being determined
through the EST phenomenon.
A specific example of dismissal is the renowned Smith et. al (1980)
analysis of 475 studies which concludes that psychotherapy of all
kinds is generally more effective than no treatment. The study is
disregarded primarily on the basis that it pre-dates the Beck et. al.
Manual and DSM-III (Garfield, 1996). The faux pas of dismissing the
1980 analysis has been raised anew by a meta-analysis in the
November, 1997 issue of the Psychological Bulletin (Wampold, et.
al.) which re-confirms the Smith et. al. study. Elliott (1997) also reconfirms these findings in his summary of meta-analysis.
Conclusion 3: The findings of five decades of psychotherapy
outcome research have discovered that the clientdriven/person-centered paradigm accounts for the major
success variance for clients.

10

The most cogent conclusions of this research are:

- That the type of therapy and technique is largely irrelevant in
terms of successful outcome;
- That there is little evidence to support the position that there are
specific treatments for particular disabilities; and
- That the influence of treatment models pales in comparison to the
personal qualities of the individual therapist. (Luborsky et al., 1986).
The most clear research evidence is that effective psychotherapy
results from the resources of the 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
quantitative research (e. g. , Lambert, 1992; Lambert, Shapiro &
Bergin, 1986) that offer data to develop a model for clinical practice.
It bears repeating that these reviews conclude that 30% of the
outcome success variance is accounted 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% of the
successful therapy is accounted for by therapist and client variables.
Techniques account for only 15% of the success variance and that is
similar to the 15% accounted for by placebo effect. Such research
findings suggest the utility of intentionally utilizing the clients frame
of reference, "courting" the client, and going with the clients
direction in therapy.
Conclusion 4: The precise functional practice of specific
treatments for a particular dysfunction is questionable.
How does the concept of EVT relate to efficacious treatment? We
asked this question to a number of therapists. Here is one response:
The question is: what do you mean by efficacious treatment? The
client comes for a panic attack: maybe they have some other things
to say; maybe you tell them something of what you know about
managing anxiety or whatever; but do you inhibit their talking about
related or non-related topics?
Right now I have a woman who has panic after a traffic accident. It
turns out that her sister who was the closest person to her died
suddenly a few years earlier. She went to the hospital for a "simple
but delicate procedure . . .", her leg had to be cut off and three
weeks later she was dead. My client was broken hearted and in
shock. This was her primary focus in the session. Now what do I do?
Do I treat her for the panic attack from the road accident, which is
11

the reason for the referral. Or listen to her more pressing concerns
as she talks about the rest of it? Do I stop her from talking about
what she expresses as her more basic difficulty?
How can it be so simple? . . .what is the definition of efficacious?
What is withholding treatment? How do you know what the problem
is, anyway even if youre intent on fixing it; if you close off the
avenue of talking about it before you begin? The doctor hadnt even
heard about the sister . . . that is how efficacious he is . . .
This is just one of maybe five panic attack cases I have right
now . . . all with tails that wag the dog.
The efficacy of treatment becomes a bit confounded in the real
world.
The myth of EST is further compromised in the violation of the
fundamental premise. The primary premise is that there are certain
procedures that will ameliorate or diminish particular dysfunction. It
is so certain that this is the case that the procedures are identified
via treatment manuals. This is pretty good because what it means is
that anyone who is reasonably intelligent can follow the procedures
and the result will be positive. In the 1960s,we did this with
behavior modification procedures that were integrated into hospitals
and schools for the mentally retarded and mentally ill. Ward
attendants, many with less than high school education, could follow
these procedures with reported successful results as long as the
procedures were followed. Many of these procedures are still in the
institutions in spite of serious questions about the validity of the
results. But, if it works as asserted, lets do it. However, somehow
we find that it requires a doctoral level psychologist to apply the
technical manual. Why is this? If the procedure is, in fact, the point
of the whole thing, then why do we need the clinical psychologist as
a treatment phenomenon? We dont! 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 variable present. That is, we need a competent clinician
in case there are clinical judgments to be made when the procedure
is not working. This means that we must be ready to change the
procedure at any given moment and that it is 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 ESTs.
The fact that five decades of psychotherapy outcome research has
been ignored in the search for specificity as highlighted by the EST
proposals is further compounded by the murkiness of "good"
research designs which support procedures that can not be trusted
without the murkiness of clinical judgment.
12

Summary
Our examination of the credibility of diagnosis, the pattern of
psychotherapy outcome research, the conclusion of five decades of
psychotherapy outcome research, and the intrinsic flaws in the
reported evidence for Empirically Supported Treatment suggest a
radical conclusion.
This conclusion is that the foundation of the mental health system in
the United States is founded upon a myth; that is, the myth that
there are specific treatments for particular dysfunction. This
conclusion calls for a radical re-structuring of the mental health
system to accentuate the variables related to success. These are
the common factor variables of therapist/client relationship and
emphasis of client resources and client frame of reference.
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