Therapy may be judged by the wrong standards, argues new analysis

Psychological therapies may be evaluated using research methods designed for drugs rather than talking treatments—potentially limiting patient choice and shaping mental health services in the wrong way—according to a new academic analysis from The University of Manchester.

Based on analyzing existing research, the article argues that Randomized Controlled Trials (RCTs), widely seen as the gold standard of medical evidence, may be a poor fit for assessing therapy.

Rather than presenting new experimental findings, the editorial brings together and critiques the current evidence base, making the case that talking therapies are often personal, flexible, relationship-based and evolve over time—characteristics that are difficult to capture in standard trial designs.

The analysis suggests that relying too heavily on RCTs may favor short, standardized therapies such as Cognitive Behavioral Therapy (CBT), while overlooking other approaches that may benefit many patients. The paper is published in The British Journal of Psychiatry.

Key arguments include:

• Psychological therapy is often assessed using research models originally developed for medicines
• Unlike drugs, therapy is typically personalized, open-ended and shaped by the therapist–client relationship
• Heavy reliance on RCT evidence may narrow treatment options in public health care and insurance systems
• Short-term symptom measures may miss broader outcomes such as improved relationships, stability and self-understanding
• A broader evidence base is needed, including real-world outcomes and patient experience

Why this matters

RCTs are commonly used to decide which treatments receive funding, policy backing and public provision.

The editorial argues that this has had significant consequences in mental health care, where therapies with strong trial evidence—particularly CBT—have become dominant in many systems.

In England’s NHS Talking Therapies program, only a small minority of high-intensity practitioners offer non-CBT approaches, according to evidence discussed in the article.

Why therapy is different from drugs

The article highlights key differences between medicines and psychological therapies.

While drugs can typically be standardized and tested under controlled conditions, therapy is more fluid. Sessions evolve in response to the individual, progress can be non-linear, and meaningful change may include outcomes that are harder to quantify.

What current evidence may miss

The editorial argues that many therapy studies are relatively short, often capturing early symptom improvement but missing longer-term change, setbacks or deeper psychological development.

It also suggests that recovery is often more complex than a single score or endpoint, and may involve ongoing change over time.

To illustrate this, the author uses a fictional case study showing how different therapy models can lead to very different long-term outcomes, even where short-term symptom improvement appears similar.

Towards a broader understanding of evidence

Rather than rejecting trials altogether, the editorial calls for a more pluralistic approach to evidence, including:

• Real-world service data from routine NHS and community settings
• Research into how therapy works, including the role of relationships and context
• Greater emphasis on patient perspectives and lived experience

What the researcher said

“We have become so used to treating Randomized Controlled Trials as the gold standard that we rarely stop to ask whether they are the right tool for every intervention,” said Dr. Sahanika Ratnayake, philosopher of psychiatry at The University of Manchester.

“This editorial is not based on a new experiment, but on analyzing the strengths and limits of the existing evidence base. Therapy is not a pill—it is a human relationship shaped by trust, timing, context and individual need. If we only reward treatments that fit the trial model, we risk overlooking approaches that help people in real life.”

Why it matters now

Demand for mental health support is rising, while services face pressure over waiting times, staffing and budgets.

The article argues that policymakers need evidence systems that better reflect how therapy is actually practiced, and what patients themselves value from care.

Provided by
The University of Manchester

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Who’s behind this story?

Gaby Clark

MA in English, copy editor since 2021 with experience in higher education and health content. Dedicated to trustworthy science news.

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Robert Egan

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