How Cookie-Cutter Treatments Are Presented as the Standard of Quality

You may have heard this phrase: “The XYZ therapy (or medication) is the gold-standard treatment for a condition ABC.”

Gold standard. Silver bullet. Treatment of choice. I agree with Jonathan Shedler¹ that these are marketing terms, not scientific descriptions. This is how a market is created: Define a problem—ABC, show that you have the solution—XYZ. Then advertise. XYZ becomes a brand name.

Such marketing is powerful, and it often works, as many patients desperately hope to hear something concrete, short, and simple that they can hold on to. By contrast, in psychotherapy with a clinician who appreciates human complexity, they may hear something like: “We need to meet a few more times to form a preliminary, mutual understanding of what is going on. A three-letter label explains little. You are not a diagnosis; you are a person in distress, with history and culture. We need more time to collect the relevant information.”

Clinicians sometimes advertise their affiliations with the gold standard—“I am an XYZ-certified, trauma-informed, person-oriented, evidence-based therapist.” We have more than 105,000 mental health professionals in the United States,¹¹ so the "gold-standard elite" must stand out, otherwise they won’t be seen among the regular Joes.

Is the psychotherapist competent? Experienced? Kind? Are you a good match with them?

Who cares! XYZ-certified!

Universality Implications

Here is what I think is not talked about when you hear the “gold-standard” statement. Picture a conveyor belt. The patients labeled with ABC jump onto it. They go through the XYZ treatment. Then, they hop off the belt and smile, all the same way. Good to go.

The “gold standard” approach universalizes clinical treatment.

It is informative to ask the person presenting the "go-to" XYZ therapy—What do they mean exactly by the “gold standard”? You are likely to hear another interesting phrase: “It works.”

For whom? In whose hands? In what circumstances? None of that. “It works” implies universality—there is a universal XYZ that works for a universal ABC.

The Psychiatrist Effect

What about the psychiatrist effect⁵—that some psychiatrists prescribing medication to patients consistently achieve better outcomes than other psychiatrists prescribing the same medication? No, XYZ works for ABC. Jonathan Shedler suggested that each therapist-patient dyad has its unique properties that emerge in that therapeutic relationship.^2,10 No. Too complex. XYZ works for ABC. There is no emergence in this formula, no transience, no context.⁶ We’ve got the Gold Standard!

Ask the gold standard-oriented person further—What do you mean by “It works”?

What you are likely to hear is: “We have research.”

Clinical Research and Real-Life Psychotherapy

Let’s unpack that. Usually, by research, they mean randomized clinical trials (RCTs.) These studies are widely used in medicine and are indeed valuable for studying some questions (e.g., vaccine efficacy).

The question of using RCTs for psychotherapy is significantly more complex than for vaccine research. One needs a manualized form of psychotherapy to conduct an RCT rigorously, while in real life patients don’t come with a manual,^1,2 like a Honda Civic. Competent psychotherapists don’t conduct therapy according to the manuals—they work with a person. Then, RCTs measure something artificial, which has little to do with real-life psychotherapy.^1,2 They measure the academic psychologists’ fantasy of psychotherapy, not the psychotherapy in daily clinical practice.^1,2 An additional issue is that most RCTs look at the outcome after a few weeks of therapy, while most patients are interested in long-term, stable results. The term for these drawbacks is poor ecological validity.

Importantly, many psychology-related RCTs are still based on another technique, which has been the “gold standard” in clinical research for decades—the “statistical significance” or the “p-value” tests.¹

Once the researchers obtain a p-value of less than 0.05, they are usually done. Ronald Fisher, who came up with this number, said upon retirement that this number was the biggest regret of his professional career.³

Psychiatry Essential Reads

It’s Time for Social Psychiatry’s Comeback

Getting Insurance to Cover Mental Health

Did you get below 0.05? Nothing else is needed. Statistical significance! XYZ is then announced as an effective treatment for ABC.

This is an example of a “gold standard treatment” based on the “gold standard research.” So much gold!

What you are not being told is that statistical significance does not mean clinical significance,^1,2 that the researchers assumed that normal distribution-based statistics are adequate for studying mental health conditions,^6,7 and that researchers commonly apply group-level statistical results to individual psychology, which is a problem with group-to-person generalization [Loring Ingraham, personal communications⁹].

Here is a citation from a key paper on the subject by W. Sulis (2021): “In psychology, it has taken decades to move beyond the almost dogmatic devotion to the Normal distribution, and the recognition that many situations possess a very different probability structure, particularly power law distributions."^6,7

Well, not everyone has moved beyond the normal distribution; many continue to tell us that p-value < 0.05 means that treatment XYZ is effective — for all patients, or most of them.

There is a crisis of “significance testing” in psychology research and elsewhere^3,4; the entire approach of statistical significance is being questioned in the professional literature.

You will not hear a word about this from the gold-standard people; it’s too long, messy, mathematical, and not so shiny.

But if you say you’ve got the gold standard, who will check these details?

Everyone likes gold.