Therapy Is Not a Pill, So Why Do We Test It Like One?
The way we test therapy has limited its diversity.
Posted June 1, 2026 | Reviewed by Gary Drevitch
How many therapies can you think of, off the top of your head? Psychoanalysis probably, but you might also have heard of existential, humanistic, integrative, creative, and body therapies. And then there's the therapies you might not have heard of like family constellations, internal family systems, transactional analysis, and gestalt therapy . But if you've tried to get therapy recently, particularly through a public healthcare system like the National Health Service in the UK or via Medicare in Australia, there's a good chance you would only have been offered Cognitive Behavioural Therapy. That's also what you're most likely to have been recommended if you tried to access therapy through private health insurance or an Employee Assistance Program.
I believe Cognitive Behavioural Therapy's prevalence is not due to it being uncontroversially better than other therapies. Instead, it's a complicated story about how we evaluate whether something works, what it even means to say it 'works', how medical research is funded and how decisions about which interventions to fund are made. It's a story about Randomised Controlled Trials (RCTs) .
Randomised Controlled Trials: Good for Pills, Wrong for Therapy
RCTs involve taking two groups of people who have a particular condition researchers are trying to treat or address in some way, and giving only one group the intervention. The people in the groups are similar in terms of age, gender , race, etc. and are randomly allocated to an 'active' group that gets the intervention or a control group which does not. The idea is that if you have two similar groups of people and the group which gets the intervention improves, then you can be more confident that it is because of the intervention rather than other factors.
In a piece for the British Journal of Psychiatry , I argue that while RCTs might make sense for certain kinds of things like pills, they are not a good tool for evaluating whether therapy works. RCTs work best for interventions that are brief, replicable, measurable, and where it is clear what you are targeting. Pharmaceuticals meet these conditions: They work on a relatively short time-frame; it's easy to ensure that you are giving the same intervention to all the people in the active group and to measure the effects; and what you're trying to target is often quite clear because it is usually a particular illness.
Therapy doesn't readily meet these conditions. It often takes place over an unspecified time period and is highly responsive to the needs of the client, so it is difficult to replicate. The problem being targeted is not usually specified in advance, may change, and success is often in terms of complex goals that might also shift over time.
How Therapy Has Been Adapted for RCTs
Therapy researchers have adapted therapy for RCTs in various ways. The main adaptation has been the development of therapy manuals. They describe the theories and techniques of a particular school of therapy and may provide sample scripts or plans for how a session or course of therapy might unfold. These manuals often also specify exactly what psychiatric condition the type of therapy is supposed to treat.
But standardising the type of therapy to make it replicable and specifying its target in terms of diagnosis is at odds with how many therapists practice.
Many schools of therapy, for instance humanistic therapy , explicitly avoid conceptualising the client's problems in terms of psychiatric diagnoses. Most schools of therapy also aspire to be "client-led", so the problem being addressed is identified and described by the client rather than specified in advance.
Therapy manuals are restricted to a specific type of therapy. But most practitioners work "eclectically" , meaning that they draw on techniques and theories from multiple types of therapy depending on what they think their client needs. For example, in the UK, 87% of practitioners responding to a survey claimed to draw on multiple schools of therapy.
Being responsive to the client's needs also means that the length of a course of therapy is not specified in advance, but varies depending on the client's progress. In contrast, RCTs rarely cover more than 20 sessions of therapy.
Finally, progress and improvement in trials is measured by numerical scales — some of them the same ones used in drug trials, like the Hamilton Depression Scale — which focus on narrow symptom changes like better sleep. But qualitative research with patients show that they often go to therapy for more nuanced goals like self-understanding.
The Mismatch Between Therapy in RCTs and ‘In the Wild’
There is a large gap between therapy shoehorned to fit the requirements of RCTs and therapy as it is practiced routinely. The discrepancy is similar to a different drug being prescribed by pharmacies than the drug tested during RCTs. This mismatch is about how practitioners and clients understand therapy and how it should be practiced — something that, when it is done well, is open-ended, flexible and highly responsive to the client's needs and goals.
RCTs do not really seem to be testing whether therapy works. They are looking at whether something that has been heavily altered to fit the shape of RCTs works.
RCTs are a tool for evaluating efficacy. They are not an end in themselves. Forcing therapy to conform to the shape of RCTs instead of trying to find more appropriate research tools has diminished the range of available therapies to the ones that are most able to mould themselves to RCTs.
Decisions about which therapies to offer via public healthcare or which to recommend by institutions such as the National Institute for Healthcare Excellence in the UK or the National Institute for Mental Health in the US, rely almost exclusively on RCT data. It is also easier to publish in prestigious journals and get research funding for RCTs than other types of research. So the therapies that are most prevalent now — like Cognitive Behavioural Therapy — are the ones that have most successfully adapted themselves for RCTs. Other therapies, which have been less quick or less able to adapt to RCTs, are becoming increasingly harder to access.
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Sahanika Ratnayake, Ph.D., is a philosopher of medicine and psychiatry specializing in contemporary therapy, namely Cognitive Behavioural Therapy and Mindfulness.
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This article is part of the Bringwise Psychology Journal — daily insights on human behavior, mental health, and personal growth.