Dr. Sahanika Ratnayake, a philosopher of psychiatry at The University of Manchester, has challenged one of the most fundamental assumptions in modern mental health care: that the same gold-standard research method used to test medicines should also be used to evaluate talking therapies. Her new analysis, published in The British Journal of Psychiatry, argues that this mismatch may be quietly reshaping which treatments patients can access—often in ways that narrow choice rather than expand it.
Randomized Controlled Trials, or RCTs, have become the currency of medical evidence. Governments, insurance systems, and health services use them to decide which treatments get funding and public provision. But Ratnayake's work reveals a crucial problem: the methods that work brilliantly for standardized pills work poorly for human relationships. Unlike a drug, which can be identical in every dose and tested under controlled conditions, therapy is inherently personal, flexible, and shaped by the trust and timing between therapist and client. Sessions evolve in response to the individual, progress rarely moves in a straight line, and meaningful change often involves outcomes that resist simple measurement—like improved relationships, deeper self-understanding, or newfound stability.
When health systems rely too heavily on RCT evidence, Ratnayake argues, they inadvertently favor short, standardized approaches like Cognitive Behavioral Therapy (CBT), which fit the trial model neatly. Other therapies that may help many patients—but are harder to standardize or test quickly—get overlooked. In England's NHS Talking Therapies program, for example, only a small minority of high-intensity practitioners offer non-CBT approaches, a pattern visible across many health systems worldwide. The consequence is real: patients with different needs and preferences may find themselves channeled toward one model of care, not because it works best for them, but because it works best in a trial.
The analysis also highlights what current research methods systematically miss. Most therapy studies are relatively short, capturing early symptom improvement without following patients long enough to see deeper changes, setbacks, or genuine psychological development. Recovery, Ratnayake argues, is rarely a single endpoint. It is often ongoing, complex, and includes transformation that numbers alone cannot capture.
Yet her editorial is not a call to abandon evidence. Instead, Ratnayake advocates for a more pluralistic approach—one that includes real-world data from NHS and community settings, research into how therapy actually works through relationships and context, and greater attention to what patients themselves report about their experience. The goal is not less evidence, but better evidence, matched to what therapy actually is.
The timing matters. Demand for mental health support is rising steeply while services face intense pressure on waiting times, staffing, and budgets. Decisions made now about which therapies to fund and promote will shape care for years to come. As Ratnayake puts it, if we only reward treatments that fit the trial model, we risk overlooking approaches that genuinely help people in real life. The question is whether mental health care will expand to meet diverse human need, or narrow to fit the tools we happen to measure best.