The general public may want these things but all psychotherapy and its evidence base is completely oversold, over promoted and the harms ignored or minimised.
Is it not way past time for a large portion of humble pie and some some honesty?
‘regulating emotions’ is such a weird idea – emotions like so much else are automatic and determined by a range of mostly unconscious factors none of us control.
These are just standard models being used as guides – they are being perfected all the time and new models are coming more tuned to life guidance/therapy – The therapy industry is also completely oversold in terms of its actual evidence base and there are countless human therapists causing a lot of harm, while ignorantly thinking they are helping.
Critical Perspectives on Therapy Efficacy: Executive Summary
Overview
A growing body of critical literature challenges the widespread claims of psychotherapy effectiveness, revealing significant gaps between promoted benefits and actual outcomes. This summary synthesizes key critiques from methodological, institutional, social, and clinical perspectives, offering practicing therapists a framework for critically evaluating efficacy claims.
Major Critical Voices and Their Arguments
Scott Lilienfeld: The Methodological Critic
Core Argument: Many therapies appear effective due to systematic biases and methodological flaws rather than actual therapeutic benefit.
Key Insights:
Cognitive biases (confirmation bias, availability heuristic) lead therapists and clients to perceive improvement where none exists
Publication bias suppresses negative results, creating false impression of universal effectiveness
Regression to the mean often gets mistaken for therapeutic progress
Allegiance effects – researchers find their preferred treatments work better
Iatrogenic effects: some therapies actually cause harm but this is underreported
Clinical Implications: Therapists should actively look for disconfirming evidence and be aware of their own cognitive biases when evaluating treatment outcomes.
William M. Epstein: The Institutional Critic
Core Argument: Psychotherapy lacks credible scientific evidence and persists primarily because it serves cultural and professional interests rather than client welfare.
Key Insights:
Describes psychotherapy as “immensely popular but consistently ineffective”
Argues the field functions more like a religion than a medical treatment
Research base is fundamentally flawed – methodological problems are endemic, not occasional
Therapy perpetuates American values of individualism and self-reliance
Professional and commercial interests maintain ineffective practices
Clinical Implications: Practitioners should question whether their work truly helps clients or primarily serves professional/institutional needs.
David Smail: The Social Materialist Critic
Core Argument: Psychological distress stems from material social conditions and power relations, not individual pathology. Therapy obscures real causes by focusing on internal psychological states.
Key Insights:
Distress is “a material circumstance, not a psychological condition”
Power differences create distress – therapy cannot change power relations through talking
CBT wrongly converts powerlessness into treatable “cognitive distortions”
Real help comes through social support and addressing material conditions
Therapy only works when therapist becomes a caring friend, not through technique
Clinical Implications: Consider whether individual therapy is appropriate when problems stem from social/economic conditions beyond client control.
Paul Moloney: The Insider Critic
Core Argument: The therapy industry serves social control functions, promoting individual compliance with harmful social conditions rather than addressing systemic causes of distress.
Key Insights:
NHS clinical psychologist’s insider perspective on how therapy functions within healthcare systems
Therapy promotes acceptance of status quo rather than social change
Industry growth driven by professional interests, not evidence of effectiveness
Medicalization of normal human distress serves institutional rather than individual needs
Clinical Implications: Examine whether therapeutic interventions help clients adapt to harmful situations rather than addressing underlying problems.
Sami Timimi: The Critical Psychiatrist
Core Argument: Psychiatric diagnoses are primarily cultural constructions that obscure rather than explain children’s difficulties, with therapy often serving to medicalize normal responses to social problems.
Key Insights:
Skeptical of the benefits of psychiatric diagnosis, seen as primarily cultural constructions
Has critiqued the medicalisation of the various problems subsumed under the categories of ADHD and autism
Psychiatric diagnoses like ‘ADHD’ do more to obscure what really matters
Advocates for understanding children within family and cultural context rather than through diagnostic labels
Has described global mental health initiatives as a form of neo-liberalism
Clinical Implications: Question whether diagnostic frameworks help or hinder understanding of client difficulties, especially with children and families.
Methodological Issues: What the Research Really Shows
Publication Bias and the File Drawer Problem
Studies showing therapy effectiveness get published; null results disappear
Creates false impression that all therapies work for all conditions
Turner et al. (2008) showed antidepressant effectiveness dropped from 94% to 51% when unpublished studies included
Effect Size Inflation
Meta-analyses consistently show smaller effects when publication bias corrected
Cuijpers’ recent work shows how different analytical choices dramatically affect conclusions
Clinical significance often much lower than statistical significance
Research Design Problems
Allegiance effects: researchers find their preferred treatments superior
Lack of appropriate control groups (many studies compare therapy to no treatment rather than alternative approaches)
Short-term follow-up misses long-term outcomes
Selective outcome reporting emphasizes positive measures
The Common Factors Problem
Most therapeutic benefit may come from non-specific factors (relationship, hope, attention)
Specific techniques may add little beyond common factors
Questions whether expensive training in specific modalities is justified
Recent Evidence: The 2022 Umbrella Review
The comprehensive 2022 umbrella review by Dragioti et al. examining 33 meta-analyses found that therapy efficacy “may be overestimated, due to a variety of shortcomings” including:
Publication bias across multiple treatment types
Methodological limitations in primary studies
Inconsistent findings when bias corrections applied
Limited long-term follow-up data
Implications for Clinical Practice
Immediate Considerations
Maintain Therapeutic Humility: Acknowledge uncertainty about what actually helps clients
Focus on Relationship: Emphasize genuine care and support over specific techniques
Address Material Conditions: Consider whether problems require practical rather than psychological solutions
Monitor Outcomes Carefully: Use objective measures and actively look for lack of progress
Avoid Overconfident Claims: Be honest about limited evidence for many interventions
Ethical Questions
Is it ethical to provide treatments with questionable evidence base?
How do we balance hope with honesty about treatment limitations?
When does therapy become a form of social control rather than genuine help?
Should we focus more on social advocacy than individual treatment?
Professional Development
Develop critical thinking skills for evaluating new treatments
Understand research methodology to identify flawed studies
Consider broader social context of client problems
Maintain awareness of cognitive biases affecting clinical judgment
Key Therapeutic Approaches Under Scrutiny
Cognitive Behavioral Therapy (CBT)
Declining effect sizes in recent meta-analyses
Questions about whether cognitive change drives behavioral improvement
May blame individuals for problems caused by social conditions
EMDR
Controversy over eye movement component
Some evidence suggests exposure elements, not eye movements, drive benefit
Questions about theoretical foundation
Third Wave Therapies (Mindfulness, ACT)
Mixed evidence with potential publication bias
Questions about whether benefits exceed simpler interventions
Cultural appropriation concerns with mindfulness approaches
Moving Forward: A Balanced Perspective
While these critiques raise serious questions about therapy effectiveness, they don’t necessarily mean all therapeutic work is useless. Instead, they suggest:
Honest Assessment: Acknowledge limitations of evidence base
Focus on Fundamentals: Prioritize genuine human connection and practical support
Address Root Causes: Consider social and material factors contributing to distress
Professional Humility: Avoid overclaiming about treatment capabilities
Continuous Learning: Stay informed about methodological issues in research
Conclusion
The critical literature reveals significant problems with claims about therapy effectiveness, from methodological flaws to institutional biases to misunderstanding the nature of human distress. Rather than abandoning therapeutic work entirely, these critiques call for more honest, humble, and socially aware practice that prioritizes genuine client welfare over professional interests.
The gap between therapy claims and actual effectiveness may be larger than commonly acknowledged, but this creates an opportunity for more authentic and potentially helpful approaches that focus on real human connection and addressing the actual conditions that create distress.
Key References
Essential Critical Texts:
Epstein, W. M. (2006).Ā Psychotherapy as Religion: The Civil Divine in America. University of Nevada Press.
Epstein, W. M. (2019).Ā Psychotherapy and the Social Clinic in the United States: Soothing Fictions. Palgrave Macmillan.
Lilienfeld, S. O., Ritschel, L. A., Lynn, S. J., Cautin, R. L., & Latzman, R. D. (2014). Why ineffective psychotherapies appear to work: A taxonomy of causes of spurious therapeutic effectiveness.Ā Perspectives on Psychological Science, 9(4), 355-387.
Moloney, P. (2013).Ā The Therapy Industry: The Irresistible Rise of the Talking Cure, and Why It Doesn’t Work. Pluto Press.
Smail, D. (2005).Ā Power, Interest and Psychology: Elements of a Social Materialist Understanding of Distress. PCCS Books.
Smail, D. (2001).Ā Why Therapy Doesn’t Work. Robinson.
Timimi, S. (2021).Ā Searching for Normal: The Complexities of Diagnosis in a Digital Age. Jessica Kingsley Publishers.
Key Research Studies:
Cuijpers, P., et al. (2023). Exploring the efficacy of psychotherapies for depression: A multiverse meta-analysis.Ā Behaviour Research and Therapy, 168, 104179.
Dragioti, E., et al. (2022). The efficacy of psychotherapies and pharmacotherapies for mental disorders in adults: An umbrella review.Ā World Psychiatry, 21(1), 72-94.
Turner, E. H., Matthews, A. M., Linardatos, E., Tell, R. A., & Rosenthal, R. (2008). Selective publication of antidepressant trials and its influence on apparent efficacy.Ā New England Journal of Medicine, 358(3), 252-260.
This summary synthesizes critiques from multiple sources. For complete arguments and evidence, consult the full reading list and original sources.
such a curious world where one off the cuff comment oh this is classic ……fill in the blank, suddenly helps to create a story for people and then becomes real. How many times have I read and heard similar stories – people being diagnosed with this or that DSM construct, believing they’ve been misdiagnosed until someone else offers another ‘diagnosis’ story that works with whatever story the person has already come to tell themselves. Its all story.
At any age there are huge changes happening to us that we might be struggling to make sense of or understand and especially at 15. From what i’ve read the young man was badly burned and this might well be visible on his body/face and we’re extremely self conscious and living in cultures that ensure we are so we can spend money to change ourselves. We’re also acutely attuned to being judged by others.
The shifts to language are part of a broader and constant shifting of language.
The cultural pendulum oiled with self interest, profit and ignorance swings vastly too far in one direction and just like all other consumer brands DSM labels/language are popularised and then we get push back and it swings in totally the opposite direction – if we’re lucky we might find a middle way at some stage – in the meantime how about we listen to people’s stories and seek understanding and support before we label them.
Try William M Epstein’s work on the evidence base for therapy – he takes apart the best of the studies and looks in detail at them on methodological grounds for a range of so called evidence based therapies EMDR included – he shoes they are of terrible quality – try this AI summarised from Epstein re EMDR:
1. Questionable Scientific Foundations
Epstein argues that EMDRās mechanismsāsuch as the bilateral stimulation through eye movementsālack a plausible scientific rationale. He sees the theoretical foundation of EMDR as vague or unsubstantiated, especially the claim that eye movements can facilitate the processing of traumatic memories.
2. Flawed Research Methodologies
He critiques the research supporting EMDR as methodologically weak. Specifically, he points to:
Small sample sizes.
Poor controls in experimental design.
Selective reporting of positive outcomes.
Lack of long-term follow-up in many studies.
Epstein contends that the apparent effectiveness of EMDR in trials often reflects these methodological issues rather than true therapeutic efficacy.
3. The Placebo Problem
Epstein suggests that EMDR may function primarily as a placebo, with any effectiveness arising from nonspecific therapeutic factorsālike attention, suggestion, and structured supportārather than from the specific techniques (e.g., eye movements) claimed to be central to EMDR.
4. Ideological and Institutional Interests
He argues that the popularity and institutional acceptance of EMDR (including endorsements by organizations like the APA and WHO) may reflect political and ideological pressures more than scientific validity. Epstein frequently emphasizes that practices often become “evidence-based” through institutional mechanisms rather than through genuinely rigorous testing.
5. Critique of the āEvidence-Basedā Label
In line with his wider critique of evidence-based practice, Epstein sees the validation of EMDR as an example of how the label “evidence-based” can be misleading. He argues that what counts as “evidence” is often defined in ways that support prevailing professional, political, or commercial interests, rather than representing a true scientific consensus.
In Summary:
Epstein views the evidence base for EMDR as methodologically suspect, theoretically weak, and ideologically driven. He uses EMDR as a case study in how unproven or poorly understood treatments can gain legitimacy through flawed science and institutional endorsement, rather than through robust empirical validation.
Let me know if youād like quotes or references from Epsteinās works to support this summary.
such a bananas world, time after time we ignorantly swallow chemicals for DSM nonsense with zero informed consent, but even the fully duped must surely know chemicals have consequences?
encouraging resource poor people to attend therapy when they suffer with so many cultural disorders causing their distress is useful to power because it helps to obfuscate said cultural disorders. Therapy can be next to useless if not actively harmful for the individual – its not the cultural disorders dummy, we likely won’t mention those or at best reduce them to a mere trigger for the real issue is your disordered thoughts, behaviours, attitudes and beliefs – lets just keep trying to force square pegs into round holes and lets make sure there’s disorder and drug for everyone. Congratulations you scored below ‘clinical’ on the PHQ9 its a miracle you are now in recovery and you didn’t even realise it!
Be good to get more of these sorts of analyses out into the public domain and keep them there
The industry simply drowns out anything that challenges its credibility and continuance, as is to be expected in capitalist neoliberal order.
Be great to see an interview with William M Epstein or at least detailed reviews of this three key books The Illusion of Psychotherapy, Psychotherapy as Religion and Psychotherapy and the social clinic in the united states, soothing fictions.
We need to move on for this internalising profitable mess and start diagnosing and treating our many and growing cultural disorders causing so much distress.
This ‘schizophrenia’ needs a ‘disorder’ make over crew on the job, a bit like ‘adhd’ and ‘asd’ have had – get the celebs involved, get some cooler drugs that people don’t mind taking and others not labelled quite like to snort.
Then pepper the entire culture with questionnaires, blogs and other ‘influencers’ to get into people heads, ensure the criteria is so loose and broad that pretty much anyone can see themselves, encourage self diagnosis and reframe it as a ‘super power’.
I can see a TV series with make up artists, set designs and sharp looking ‘professionals’ in white coats – maybe call it Neuro Island or the great British Neuro off. Got to get away from the poor marketing strategy of ‘disorder’ and find a more appealing, desirable, marketing plan and sell sell sell.
Soon, everyone and their dog will completely jettison any pesky life contexts, histories and political and economic systems and come to embrace their ‘true’ ‘adhd’ ‘asd’ ‘shizzlephreniababy’ selves and shed their ‘masking’ and start rising up against all those silly neuro typicals with their vanilla, easy lives, just gliding through life as if invisible butterfly wings carry them above and beyond the ‘masking’ they always seem to force our hidden super neuro hero’s to wear – no more!!!
I will show them all! I too can self diagnose, get me some cool drugs and fly into our neurobabbling, brain shrinkage, heart attack, ‘reasonable adjustments’ psychotic, drug addled future freeeeeeedom!!! lube me up I’m going in.
has it replicated?, how robust are the protocols? is it studying something concrete rather than an amorphous construct? where its impossible to control for all the variables, what about bias? what about the long and winding road of critical research showing no psychotherapy has any robust efficacy supporting it and the foundational studies like smith and glass are also rubbish? not to mention the constant headlines like this one that don’t really amount to much at all.
It seems we can spin research in anyway so desired. What about the harms of psychotherapy and the people it can tip over into suicide? – one thing you read over and over again are sentences like ‘the harms of psychotherapy are well known but under researched’
This psychiatric and drug industry, neoliberal mess is by far the most destructive iteration that the pseudoscience of Psychiatry has ever unleashed and given its history thats really saying something.
How is it possible for a so called medical speciality to reinvent itself over and over again with zero science and with each reinvention causing ever more harm and yet it just goes along on its destructive but HIGHLY profitable and useful to power way. Just answered my own question there.
Even that captain of contradiction Allen Frances predicated back in 2013 in his book ‘saving normal’ that we would see ‘a fake epidemic of adhd, bi polar and autism’ Did he have some crystal ball skills? no, he just realised that by lowering the criteria for all sorts of DSM constructs ever more ‘normal’ behaviour would be reframed as mental illness now the fashionable ‘neuro’ diverse – the Nikes of psychiatry – people are literally lining up to be labelled and drugged on mass its utterly crackers.
who doesn’t have lived experience? a disturbing issue I see is the amount of academics and others self diagnosing or seeking a label especially the highly marketable, lucrative, easy to fake, nice drugs, so called ‘adhd’
All we have are stories – if we’ve been through therapy there are often many reasons why a story of help or hindrance is told and most of these reasons will be out of our awareness, how we slept, what we’ve eaten and when, are we hydrated, in the moment perceptions of the person asking the questions, and the various hormones and electrical chaos moving within and around us and myriad other influences beyond what Smail referred to as our ‘awareness horizon’
It would be handy to estimate how much money has gone into this ‘research’ or ghost hunting nonsense and how many millions of people have been duped into accepting this marketing ploy as a real disorder. Informed Consent simply does not exist in the mental ill health industry.
The PHQ9 has got to be one of the most dangerous tick box questionnaires ever deployed – it inflates several fold the likelihood you will be labelled ‘depressed’ or ‘GAD’ – not surprising considering it was the brain child of a marketing man called Howard Kroplick employed by Pfizer. Tasked with the job of expanding drug prescribing by creating something primary care GP’s could administer in a brief entirely insufficient consultation. The idea was then taken up by Spitzer based on his ‘criteria’ for ‘depression’. When asked by James Davies in his book cracked why this many ‘symptoms’ and not say more or less – Spitzer replied stating that more more just seemed like too many and less too few – ZERO science and has led to millions of people being prescribed with ZERO informed consent drugs marketed as ‘antidepressants’ they no longer need, benefit from and are often harmed by.
The term ‘antidepressant’ was minted once drug companies realised they had a market for their new drug if only they could expand this market via well funded campaigns like defeat depression etc. The regulator granted the use of the term after just two crap studies showing a non statistically significant reduction on another tick box the Ham D.
Diagnosis or the identification of any presumed difference doesn’t exist in psychiatry. It’s all misdiagnosis based on ever broadening and loosening ‘criteria’ for some subjective opinion of ‘on the spectrum’ out of control harmful medicalisation is everywhere.
Yes a truly draw dropping book exposing massive abuses of power and ultimate hubris. His other book the assault on truth is also a must read. Where are the exposures of all the modern schools? William m epstein’s books on psychotherapy are excellent at demonstrating the poor quality of the research and points to harms.
Pretty disgraceful that after over 100 years of psychotherapy the field doesnāt seem to bother itself with the harms its doing to people. Anyone working in the field who takes the care to ask about former therapy from their clients will hear a range of negative impacts and Iāve had my own personal negative experiences in therapy.
Therapists are in positions of perceived cultural power and sanctioned by the state. The general public, generally put us on a pedestal and believe the hype of āevidence basedā etc. This means whatever we say can influence people positively or negatively we cannot know which.
Consider therapy is mostly done on the therapists terms, in some office at a certain time/day. One is perceived as client the other professional, one discloses painful parts the other next to nothing, one is exposed the other protected.
Weāre all speaking from whatever complex interactions are going on for us in this moment along with being tied to an equally complex history. We have little access to some personal truth of things but come with our own biases, heuristics, and resources, often very limited.
Most therapists havenāt a clue what life is actually like for the person sitting in front of them, so weāre operating in near total ignorance of the person devoid of living context.
What could do wrong? a little self esteem raising or āassertiveness trainingā maybe leads to being beaten up by a violent partner, or fill in a never ending blank of potential harms that most therapists and clients are oblivious to until the influences influence a life in random and unknowable ways.
Just consider the drop out rate in state ran services such as Talking Therapies, formally IAPT, its massive!
Yet no one bothers to follow these people up, no one seems to care and their place is immediately filled with another person on a sort of conveyor belt of suffering where success is measured by utter nonsense like a score on the PHQ9.
just astonishing and terrifying that this continues to happen, its surely criminal?
Neoliberalism takes our worst human parts and explodes them into giant profit and status seeking monsters, feeding on other people at every opportunity.
I’d love to see Ioannidis do a similar review on clinical psychology and psychotherapy research since the replication crisis came to light. The research base for clin psy and psychotherapy is also complete garbage, riddled various with biaes, small samples, attrition, mixed measures, subjectivity, misrepresentation of the data and an inability to actual discern or agree on what they are actually ‘treating’ or design a placebo and on and on.
its astonishing how little interest there is in the harms caused by psychotherapy and how many therapists appear blissfully unaware that therapy can and does harm people.
It is also remarkable that psychotherapy persists given the dire state of the research base – try William M Epstein’s three key books – The illusion of Psychotherapy, Psychotherapy as religion and Psychotherapy and the social clinic in the united states, soothing fictions to be left i no doubt how terrible the research actually is.
The general public may want these things but all psychotherapy and its evidence base is completely oversold, over promoted and the harms ignored or minimised.
Is it not way past time for a large portion of humble pie and some some honesty?
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‘regulating emotions’ is such a weird idea – emotions like so much else are automatic and determined by a range of mostly unconscious factors none of us control.
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These are just standard models being used as guides – they are being perfected all the time and new models are coming more tuned to life guidance/therapy – The therapy industry is also completely oversold in terms of its actual evidence base and there are countless human therapists causing a lot of harm, while ignorantly thinking they are helping.
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Critical Perspectives on Therapy Efficacy: Executive Summary
Overview
A growing body of critical literature challenges the widespread claims of psychotherapy effectiveness, revealing significant gaps between promoted benefits and actual outcomes. This summary synthesizes key critiques from methodological, institutional, social, and clinical perspectives, offering practicing therapists a framework for critically evaluating efficacy claims.
Major Critical Voices and Their Arguments
Scott Lilienfeld: The Methodological Critic
Core Argument: Many therapies appear effective due to systematic biases and methodological flaws rather than actual therapeutic benefit.
Key Insights:
Cognitive biases (confirmation bias, availability heuristic) lead therapists and clients to perceive improvement where none exists
Publication bias suppresses negative results, creating false impression of universal effectiveness
Regression to the mean often gets mistaken for therapeutic progress
Allegiance effects – researchers find their preferred treatments work better
Iatrogenic effects: some therapies actually cause harm but this is underreported
Clinical Implications: Therapists should actively look for disconfirming evidence and be aware of their own cognitive biases when evaluating treatment outcomes.
William M. Epstein: The Institutional Critic
Core Argument: Psychotherapy lacks credible scientific evidence and persists primarily because it serves cultural and professional interests rather than client welfare.
Key Insights:
Describes psychotherapy as “immensely popular but consistently ineffective”
Argues the field functions more like a religion than a medical treatment
Research base is fundamentally flawed – methodological problems are endemic, not occasional
Therapy perpetuates American values of individualism and self-reliance
Professional and commercial interests maintain ineffective practices
Clinical Implications: Practitioners should question whether their work truly helps clients or primarily serves professional/institutional needs.
David Smail: The Social Materialist Critic
Core Argument: Psychological distress stems from material social conditions and power relations, not individual pathology. Therapy obscures real causes by focusing on internal psychological states.
Key Insights:
Distress is “a material circumstance, not a psychological condition”
Power differences create distress – therapy cannot change power relations through talking
CBT wrongly converts powerlessness into treatable “cognitive distortions”
Real help comes through social support and addressing material conditions
Therapy only works when therapist becomes a caring friend, not through technique
Clinical Implications: Consider whether individual therapy is appropriate when problems stem from social/economic conditions beyond client control.
Paul Moloney: The Insider Critic
Core Argument: The therapy industry serves social control functions, promoting individual compliance with harmful social conditions rather than addressing systemic causes of distress.
Key Insights:
NHS clinical psychologist’s insider perspective on how therapy functions within healthcare systems
Therapy promotes acceptance of status quo rather than social change
Industry growth driven by professional interests, not evidence of effectiveness
Medicalization of normal human distress serves institutional rather than individual needs
Clinical Implications: Examine whether therapeutic interventions help clients adapt to harmful situations rather than addressing underlying problems.
Sami Timimi: The Critical Psychiatrist
Core Argument: Psychiatric diagnoses are primarily cultural constructions that obscure rather than explain children’s difficulties, with therapy often serving to medicalize normal responses to social problems.
Key Insights:
Skeptical of the benefits of psychiatric diagnosis, seen as primarily cultural constructions
Has critiqued the medicalisation of the various problems subsumed under the categories of ADHD and autism
Psychiatric diagnoses like ‘ADHD’ do more to obscure what really matters
Advocates for understanding children within family and cultural context rather than through diagnostic labels
Has described global mental health initiatives as a form of neo-liberalism
Clinical Implications: Question whether diagnostic frameworks help or hinder understanding of client difficulties, especially with children and families.
Methodological Issues: What the Research Really Shows
Publication Bias and the File Drawer Problem
Studies showing therapy effectiveness get published; null results disappear
Creates false impression that all therapies work for all conditions
Turner et al. (2008) showed antidepressant effectiveness dropped from 94% to 51% when unpublished studies included
Effect Size Inflation
Meta-analyses consistently show smaller effects when publication bias corrected
Cuijpers’ recent work shows how different analytical choices dramatically affect conclusions
Clinical significance often much lower than statistical significance
Research Design Problems
Allegiance effects: researchers find their preferred treatments superior
Lack of appropriate control groups (many studies compare therapy to no treatment rather than alternative approaches)
Short-term follow-up misses long-term outcomes
Selective outcome reporting emphasizes positive measures
The Common Factors Problem
Most therapeutic benefit may come from non-specific factors (relationship, hope, attention)
Specific techniques may add little beyond common factors
Questions whether expensive training in specific modalities is justified
Recent Evidence: The 2022 Umbrella Review
The comprehensive 2022 umbrella review by Dragioti et al. examining 33 meta-analyses found that therapy efficacy “may be overestimated, due to a variety of shortcomings” including:
Publication bias across multiple treatment types
Methodological limitations in primary studies
Inconsistent findings when bias corrections applied
Limited long-term follow-up data
Implications for Clinical Practice
Immediate Considerations
Maintain Therapeutic Humility: Acknowledge uncertainty about what actually helps clients
Focus on Relationship: Emphasize genuine care and support over specific techniques
Address Material Conditions: Consider whether problems require practical rather than psychological solutions
Monitor Outcomes Carefully: Use objective measures and actively look for lack of progress
Avoid Overconfident Claims: Be honest about limited evidence for many interventions
Ethical Questions
Is it ethical to provide treatments with questionable evidence base?
How do we balance hope with honesty about treatment limitations?
When does therapy become a form of social control rather than genuine help?
Should we focus more on social advocacy than individual treatment?
Professional Development
Develop critical thinking skills for evaluating new treatments
Understand research methodology to identify flawed studies
Consider broader social context of client problems
Maintain awareness of cognitive biases affecting clinical judgment
Key Therapeutic Approaches Under Scrutiny
Cognitive Behavioral Therapy (CBT)
Declining effect sizes in recent meta-analyses
Questions about whether cognitive change drives behavioral improvement
May blame individuals for problems caused by social conditions
EMDR
Controversy over eye movement component
Some evidence suggests exposure elements, not eye movements, drive benefit
Questions about theoretical foundation
Third Wave Therapies (Mindfulness, ACT)
Mixed evidence with potential publication bias
Questions about whether benefits exceed simpler interventions
Cultural appropriation concerns with mindfulness approaches
Moving Forward: A Balanced Perspective
While these critiques raise serious questions about therapy effectiveness, they don’t necessarily mean all therapeutic work is useless. Instead, they suggest:
Honest Assessment: Acknowledge limitations of evidence base
Focus on Fundamentals: Prioritize genuine human connection and practical support
Address Root Causes: Consider social and material factors contributing to distress
Professional Humility: Avoid overclaiming about treatment capabilities
Continuous Learning: Stay informed about methodological issues in research
Conclusion
The critical literature reveals significant problems with claims about therapy effectiveness, from methodological flaws to institutional biases to misunderstanding the nature of human distress. Rather than abandoning therapeutic work entirely, these critiques call for more honest, humble, and socially aware practice that prioritizes genuine client welfare over professional interests.
The gap between therapy claims and actual effectiveness may be larger than commonly acknowledged, but this creates an opportunity for more authentic and potentially helpful approaches that focus on real human connection and addressing the actual conditions that create distress.
Key References
Essential Critical Texts:
Epstein, W. M. (2006).Ā Psychotherapy as Religion: The Civil Divine in America. University of Nevada Press.
Epstein, W. M. (2019).Ā Psychotherapy and the Social Clinic in the United States: Soothing Fictions. Palgrave Macmillan.
Lilienfeld, S. O., Ritschel, L. A., Lynn, S. J., Cautin, R. L., & Latzman, R. D. (2014). Why ineffective psychotherapies appear to work: A taxonomy of causes of spurious therapeutic effectiveness.Ā Perspectives on Psychological Science, 9(4), 355-387.
Moloney, P. (2013).Ā The Therapy Industry: The Irresistible Rise of the Talking Cure, and Why It Doesn’t Work. Pluto Press.
Smail, D. (2005).Ā Power, Interest and Psychology: Elements of a Social Materialist Understanding of Distress. PCCS Books.
Smail, D. (2001).Ā Why Therapy Doesn’t Work. Robinson.
Timimi, S. (2021).Ā Searching for Normal: The Complexities of Diagnosis in a Digital Age. Jessica Kingsley Publishers.
Key Research Studies:
Cuijpers, P., et al. (2023). Exploring the efficacy of psychotherapies for depression: A multiverse meta-analysis.Ā Behaviour Research and Therapy, 168, 104179.
Dragioti, E., et al. (2022). The efficacy of psychotherapies and pharmacotherapies for mental disorders in adults: An umbrella review.Ā World Psychiatry, 21(1), 72-94.
Turner, E. H., Matthews, A. M., Linardatos, E., Tell, R. A., & Rosenthal, R. (2008). Selective publication of antidepressant trials and its influence on apparent efficacy.Ā New England Journal of Medicine, 358(3), 252-260.
This summary synthesizes critiques from multiple sources. For complete arguments and evidence, consult the full reading list and original sources.
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How does anyone come to believe they have something called ‘autism’ or any of the other ill defined, ever changing DSM construct?
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such a curious world where one off the cuff comment oh this is classic ……fill in the blank, suddenly helps to create a story for people and then becomes real. How many times have I read and heard similar stories – people being diagnosed with this or that DSM construct, believing they’ve been misdiagnosed until someone else offers another ‘diagnosis’ story that works with whatever story the person has already come to tell themselves. Its all story.
At any age there are huge changes happening to us that we might be struggling to make sense of or understand and especially at 15. From what i’ve read the young man was badly burned and this might well be visible on his body/face and we’re extremely self conscious and living in cultures that ensure we are so we can spend money to change ourselves. We’re also acutely attuned to being judged by others.
The shifts to language are part of a broader and constant shifting of language.
The cultural pendulum oiled with self interest, profit and ignorance swings vastly too far in one direction and just like all other consumer brands DSM labels/language are popularised and then we get push back and it swings in totally the opposite direction – if we’re lucky we might find a middle way at some stage – in the meantime how about we listen to people’s stories and seek understanding and support before we label them.
Report comment
Try William M Epstein’s work on the evidence base for therapy – he takes apart the best of the studies and looks in detail at them on methodological grounds for a range of so called evidence based therapies EMDR included – he shoes they are of terrible quality – try this AI summarised from Epstein re EMDR:
1. Questionable Scientific Foundations
Epstein argues that EMDRās mechanismsāsuch as the bilateral stimulation through eye movementsālack a plausible scientific rationale. He sees the theoretical foundation of EMDR as vague or unsubstantiated, especially the claim that eye movements can facilitate the processing of traumatic memories.
2. Flawed Research Methodologies
He critiques the research supporting EMDR as methodologically weak. Specifically, he points to:
Small sample sizes.
Poor controls in experimental design.
Selective reporting of positive outcomes.
Lack of long-term follow-up in many studies.
Epstein contends that the apparent effectiveness of EMDR in trials often reflects these methodological issues rather than true therapeutic efficacy.
3. The Placebo Problem
Epstein suggests that EMDR may function primarily as a placebo, with any effectiveness arising from nonspecific therapeutic factorsālike attention, suggestion, and structured supportārather than from the specific techniques (e.g., eye movements) claimed to be central to EMDR.
4. Ideological and Institutional Interests
He argues that the popularity and institutional acceptance of EMDR (including endorsements by organizations like the APA and WHO) may reflect political and ideological pressures more than scientific validity. Epstein frequently emphasizes that practices often become “evidence-based” through institutional mechanisms rather than through genuinely rigorous testing.
5. Critique of the āEvidence-Basedā Label
In line with his wider critique of evidence-based practice, Epstein sees the validation of EMDR as an example of how the label “evidence-based” can be misleading. He argues that what counts as “evidence” is often defined in ways that support prevailing professional, political, or commercial interests, rather than representing a true scientific consensus.
In Summary:
Epstein views the evidence base for EMDR as methodologically suspect, theoretically weak, and ideologically driven. He uses EMDR as a case study in how unproven or poorly understood treatments can gain legitimacy through flawed science and institutional endorsement, rather than through robust empirical validation.
Let me know if youād like quotes or references from Epsteinās works to support this summary.
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some of this is what informed consent should look like.
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yes and no judgement, fatigue or burn out.
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such a bananas world, time after time we ignorantly swallow chemicals for DSM nonsense with zero informed consent, but even the fully duped must surely know chemicals have consequences?
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absolute rubbish.
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encouraging resource poor people to attend therapy when they suffer with so many cultural disorders causing their distress is useful to power because it helps to obfuscate said cultural disorders. Therapy can be next to useless if not actively harmful for the individual – its not the cultural disorders dummy, we likely won’t mention those or at best reduce them to a mere trigger for the real issue is your disordered thoughts, behaviours, attitudes and beliefs – lets just keep trying to force square pegs into round holes and lets make sure there’s disorder and drug for everyone. Congratulations you scored below ‘clinical’ on the PHQ9 its a miracle you are now in recovery and you didn’t even realise it!
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Be good to get more of these sorts of analyses out into the public domain and keep them there
The industry simply drowns out anything that challenges its credibility and continuance, as is to be expected in capitalist neoliberal order.
Be great to see an interview with William M Epstein or at least detailed reviews of this three key books The Illusion of Psychotherapy, Psychotherapy as Religion and Psychotherapy and the social clinic in the united states, soothing fictions.
We need to move on for this internalising profitable mess and start diagnosing and treating our many and growing cultural disorders causing so much distress.
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This ‘schizophrenia’ needs a ‘disorder’ make over crew on the job, a bit like ‘adhd’ and ‘asd’ have had – get the celebs involved, get some cooler drugs that people don’t mind taking and others not labelled quite like to snort.
Then pepper the entire culture with questionnaires, blogs and other ‘influencers’ to get into people heads, ensure the criteria is so loose and broad that pretty much anyone can see themselves, encourage self diagnosis and reframe it as a ‘super power’.
I can see a TV series with make up artists, set designs and sharp looking ‘professionals’ in white coats – maybe call it Neuro Island or the great British Neuro off. Got to get away from the poor marketing strategy of ‘disorder’ and find a more appealing, desirable, marketing plan and sell sell sell.
Soon, everyone and their dog will completely jettison any pesky life contexts, histories and political and economic systems and come to embrace their ‘true’ ‘adhd’ ‘asd’ ‘shizzlephreniababy’ selves and shed their ‘masking’ and start rising up against all those silly neuro typicals with their vanilla, easy lives, just gliding through life as if invisible butterfly wings carry them above and beyond the ‘masking’ they always seem to force our hidden super neuro hero’s to wear – no more!!!
I will show them all! I too can self diagnose, get me some cool drugs and fly into our neurobabbling, brain shrinkage, heart attack, ‘reasonable adjustments’ psychotic, drug addled future freeeeeeedom!!! lube me up I’m going in.
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has it replicated?, how robust are the protocols? is it studying something concrete rather than an amorphous construct? where its impossible to control for all the variables, what about bias? what about the long and winding road of critical research showing no psychotherapy has any robust efficacy supporting it and the foundational studies like smith and glass are also rubbish? not to mention the constant headlines like this one that don’t really amount to much at all.
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misleading headline considering the weakness of the results not to mention the vast confounding variables in anything like this.
A few years ago this was published https://www.bps.org.uk/2017/01/23/after-half-a-century-of-research-psychology-cant-predict-suicidal-behaviours-better-than-by-coin-flip.
It seems we can spin research in anyway so desired. What about the harms of psychotherapy and the people it can tip over into suicide? – one thing you read over and over again are sentences like ‘the harms of psychotherapy are well known but under researched’
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This psychiatric and drug industry, neoliberal mess is by far the most destructive iteration that the pseudoscience of Psychiatry has ever unleashed and given its history thats really saying something.
How is it possible for a so called medical speciality to reinvent itself over and over again with zero science and with each reinvention causing ever more harm and yet it just goes along on its destructive but HIGHLY profitable and useful to power way. Just answered my own question there.
Even that captain of contradiction Allen Frances predicated back in 2013 in his book ‘saving normal’ that we would see ‘a fake epidemic of adhd, bi polar and autism’ Did he have some crystal ball skills? no, he just realised that by lowering the criteria for all sorts of DSM constructs ever more ‘normal’ behaviour would be reframed as mental illness now the fashionable ‘neuro’ diverse – the Nikes of psychiatry – people are literally lining up to be labelled and drugged on mass its utterly crackers.
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neither the drugs or talk therapy have much evidence supporting them and in both cases the harms are ‘well known’ but ‘under researched’
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who doesn’t have lived experience? a disturbing issue I see is the amount of academics and others self diagnosing or seeking a label especially the highly marketable, lucrative, easy to fake, nice drugs, so called ‘adhd’
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All we have are stories – if we’ve been through therapy there are often many reasons why a story of help or hindrance is told and most of these reasons will be out of our awareness, how we slept, what we’ve eaten and when, are we hydrated, in the moment perceptions of the person asking the questions, and the various hormones and electrical chaos moving within and around us and myriad other influences beyond what Smail referred to as our ‘awareness horizon’
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It would be handy to estimate how much money has gone into this ‘research’ or ghost hunting nonsense and how many millions of people have been duped into accepting this marketing ploy as a real disorder. Informed Consent simply does not exist in the mental ill health industry.
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The PHQ9 has got to be one of the most dangerous tick box questionnaires ever deployed – it inflates several fold the likelihood you will be labelled ‘depressed’ or ‘GAD’ – not surprising considering it was the brain child of a marketing man called Howard Kroplick employed by Pfizer. Tasked with the job of expanding drug prescribing by creating something primary care GP’s could administer in a brief entirely insufficient consultation. The idea was then taken up by Spitzer based on his ‘criteria’ for ‘depression’. When asked by James Davies in his book cracked why this many ‘symptoms’ and not say more or less – Spitzer replied stating that more more just seemed like too many and less too few – ZERO science and has led to millions of people being prescribed with ZERO informed consent drugs marketed as ‘antidepressants’ they no longer need, benefit from and are often harmed by.
The term ‘antidepressant’ was minted once drug companies realised they had a market for their new drug if only they could expand this market via well funded campaigns like defeat depression etc. The regulator granted the use of the term after just two crap studies showing a non statistically significant reduction on another tick box the Ham D.
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Shockingly sick system and so many well intentioned but often incredibly ignorant people working in it.
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Diagnosis or the identification of any presumed difference doesn’t exist in psychiatry. It’s all misdiagnosis based on ever broadening and loosening ‘criteria’ for some subjective opinion of ‘on the spectrum’ out of control harmful medicalisation is everywhere.
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Thank you
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Yes a truly draw dropping book exposing massive abuses of power and ultimate hubris. His other book the assault on truth is also a must read. Where are the exposures of all the modern schools? William m epstein’s books on psychotherapy are excellent at demonstrating the poor quality of the research and points to harms.
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Pretty disgraceful that after over 100 years of psychotherapy the field doesnāt seem to bother itself with the harms its doing to people. Anyone working in the field who takes the care to ask about former therapy from their clients will hear a range of negative impacts and Iāve had my own personal negative experiences in therapy.
Therapists are in positions of perceived cultural power and sanctioned by the state. The general public, generally put us on a pedestal and believe the hype of āevidence basedā etc. This means whatever we say can influence people positively or negatively we cannot know which.
Consider therapy is mostly done on the therapists terms, in some office at a certain time/day. One is perceived as client the other professional, one discloses painful parts the other next to nothing, one is exposed the other protected.
Weāre all speaking from whatever complex interactions are going on for us in this moment along with being tied to an equally complex history. We have little access to some personal truth of things but come with our own biases, heuristics, and resources, often very limited.
Most therapists havenāt a clue what life is actually like for the person sitting in front of them, so weāre operating in near total ignorance of the person devoid of living context.
What could do wrong? a little self esteem raising or āassertiveness trainingā maybe leads to being beaten up by a violent partner, or fill in a never ending blank of potential harms that most therapists and clients are oblivious to until the influences influence a life in random and unknowable ways.
Just consider the drop out rate in state ran services such as Talking Therapies, formally IAPT, its massive!
Yet no one bothers to follow these people up, no one seems to care and their place is immediately filled with another person on a sort of conveyor belt of suffering where success is measured by utter nonsense like a score on the PHQ9.
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just astonishing and terrifying that this continues to happen, its surely criminal?
Neoliberalism takes our worst human parts and explodes them into giant profit and status seeking monsters, feeding on other people at every opportunity.
I’d love to see Ioannidis do a similar review on clinical psychology and psychotherapy research since the replication crisis came to light. The research base for clin psy and psychotherapy is also complete garbage, riddled various with biaes, small samples, attrition, mixed measures, subjectivity, misrepresentation of the data and an inability to actual discern or agree on what they are actually ‘treating’ or design a placebo and on and on.
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its astonishing how little interest there is in the harms caused by psychotherapy and how many therapists appear blissfully unaware that therapy can and does harm people.
It is also remarkable that psychotherapy persists given the dire state of the research base – try William M Epstein’s three key books – The illusion of Psychotherapy, Psychotherapy as religion and Psychotherapy and the social clinic in the united states, soothing fictions to be left i no doubt how terrible the research actually is.
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