Psychology and the Great Psychotherapy Debate
“Gloria Steinem wrote that Freud had inspired “modern psychiatry’s refreshing ability to ignore poverty, deprivation, power systems of sex, race, or class” (Osnos, 2011, p. 56).
In The Great Psychotherapy Debate, Bruce E. Wampold discusses the medical model of psychotherapy which he says consists of five components starting with a “client disorder, problem, or complaint” which, similar to medicine, by its “signs and symptoms” is assigned a diagnosis in the taxonomy of the current version of the DSM (Wampold, 2001, p. 13).
In the medical model, there is a psychological explanation for the symptoms. Wampold points out that, unlike medicine, “… for most psychological disorders, many alternative explanations exist”. He gives as an example a diagnosis of depression for which there can be many possible explanations including brain chemistry, grief, social relations, lack of pleasure, maladaptive thoughts, and more. Most important is that “some psychological explanation exists”.
Next, he says that the medical model “stipulates that each psychotherapeutic approach posit a mechanism of change”. There are then “specific therapeutic ingredients” with a current trend to “explicate these actions in manuals”.
Wampold calls the Medical Model of Psychotherapy analogous to that of medicine and points out that placebo effects, which can be distinguished in medicine, cannot be distinguished in Psychotherapy. I would add that Psychopharmacology also has difficulty in this regard, with multiple recent exposés of the diminishing effects over time of medicines in the treatment of psychological distress, e.g. (Carlat, 2010; Herper & Langreth, 2010; Hyman, 2010; Lipinski, 2010).
Evidence Based Models, Treatments, and Practices
Wampold points out that psychotherapy treatment models, including evidence based treatments, seek to standardize treatment. Treatment models are consistent “with the belief that the specific ingredients (of therapy) lead to efficacy”. Wampold shows that “practitioners have increasingly felt enormous pressure to conform to the medical model as reimbursements require diagnoses, treatment plans, and all of the other trappings of the medical model.” Importantly, he goes on to say “Nevertheless, practitioners have not, for the most part, constrained their treatments to the dictates of the manuals, and they are reluctant to shape their treatments to a unitary theoretical approach” (Wampold, 2001, pp. 17 – 20).
Wampold tells us that the “common factors” approach, which sees a “general equivalence of outcomes of (all forms of) psychotherapy”, identifies elements like the therapeutic relationship, interpersonal and social factors, corrective experiences, a confiding relationship, a plausible explanation for problems and possible solutions, client belief in the treatment, a learning experience, an opportunity to express emotions, and insight.
The Contextual Model says that the treatment procedures are beneficial because of the meaning clients attribute to them. Wampold says that, in academia, the medical model still rules over the contextual model (Wampold, 2001, pp. 21-30). Of the common factors, I consider the therapeutic relationship as is the most important, for without it, all else fails. We will look at how the increasing prevalence of the medical model threatens the therapeutic relationship, probably ending the equivalence of all models in favor of relational models and those that allow for relationship.
Wampold claims that “the research evidence is consistent with a contextual model of psychotherapy rather than a medical model” and should result in the rejection of the medical model which he says “cannot support the weight of its own evidence” (Wampold, 2001, pp. 31 – 34). If the medical model cannot be scientifically substantiated, much of the edifice of psychology is called into question including, diagnosis, treatment plans based upon diagnosis, evidence based treatments, and outcome analysis. It’s not that none of it works but that some things work in spite of the broken edifice; specifically, what works are the common factors. Unfortunately, as we will see in my agency experience, the common factors are always in danger of obliteration due to the demands of managed care, especially for the poor. Therapists practice relationally more by virtue of their own humanity and empathy than due to training or supervision. We could even say that, in some ways, the common factors constitute an “underground movement”.
While “everybody wins”, no matter what the therapeutic orientation or methodology of the psychotherapist, some “win” more than others depending on the warmth and empathy of the individual therapist. Wampold quotes Burns & Nolen-Hoeksema’s 1992 research findings: “The patients of therapists who were the warmest and most empathic improved significantly more than the patients of the therapists with the lowest empathy ratings … This indicates that even in a highly technical form of therapy such as CBT, the quality of the therapeutic relationship has a substantial impact on the degree of recovery”. Wampold concludes “The essence of therapy is embodied in the therapist… the particular treatment that the therapist delivers does not affect outcomes… The evidence is clear that the type of treatment is irrelevant, and adherence to a protocol is misguided, but yet the therapist, within each of the treatments, makes a tremendous difference … adding support for the contextual model of psychotherapy (Wampold, 2001, pp. 156, 202). Increasingly, adherence to evidence based, short term protocols damage empathy and relationship.
Social Constructionism deconstructs and has significant criticisms of psychology. “The mind becomes a form of social myth…” “facts about the nature of the psychological realm are suspended; each concept (emotion, motive, etc.) is cut away from an ontological base within the head and is made a constituent of social process” (Keneth J. Gergen, 1985).
“… we have been bathed in the rhetoric that science is both rational and progressive. In effect, by claiming themselves to be a science, supported as they are by technological accoutrements, the mental health professions fall heir to a compelling justificatory base… Technical definitions of depression are developed, case studies described, scales constructed, experimental research conducted, therapeutic strategies instituted, and treatment centers established, all of which reconstitute depression as an object of professional knowledge. Because this technical work takes place within the “scientific region” of the culture, and because science is preeminently justified, the mental health professional becomes the arbiter of knowledge about such matters” (Kenneth J. Gergen, 1997).
Nicholas Rose asks, “Why, if human beings are as heterogeneous and situationally produced as they now appear to be, did a discipline arise that promulgated such unified, fixed, interiorized, and individualized conceptions of selves, males and females, races, ages. Whose interests did such an intellectual project serve?” (Rose, 1998, p. 9) Daily, we see reports of the conflicts that shape the discipline like, “Mental health professionals warned that Governor Deval Patrick’s plan to eliminate 160 beds in mental hospitals would send ill people into jails, shelters, and emergency rooms” (Levenson, 2011).
Barry L. Duncan, Scott D. Miller, and Jacqueline A. Sparks also seek to answer parts of the question. Citing George Albee, they say that “psychology made a Faustian deal with the medical model” which they trace back to a 1949 conference in Boulder, CO , where psychologists developed a “bible”, which accepted medical language and the concept of ‘mental disease’. Later, psychologists were supported by legislation which gave them parity with psychiatrists. Psychologists could then see clients privately and get paid by third-party payers who required “only a psychiatric diagnosis for reimbursement”. Other mental health professions then sought their own “slice of the pie” without considering implications for therapy and clients. The National Institutes of Health used the randomized clinical trial (RCT) as a method of evaluation of psychotherapeutic outcomes and this methodology of research required manualized therapies and DSM-defined disorders (Duncan, Miller, & Sparks, 2004, pp. 22,23). Of the medical model, they say,
“The problem with the common beliefs and practices of the medical model shoehorned into mental health emerges when we examine them in the light of empirical research. Data from over forty years of increasingly sophisticated research shows little support for
- The utility of psychiatric diagnosis in either selecting the course or predicting the outcome of therapy (the myth of diagnosis)
- The superiority of any therapeutic approach over any other (the myth of the silver-bullet cure)
- The superiority of pharmacological treatment for emotional complaints (the myth of the magic pill)” (Duncan, et al., 2004)
Understanding how we got to the current institutions and systems can help us consider what needs to be changed. Duncan et al. suggest that we “stop allowing ourselves to be dragged behind the medical-model truck” but they do not propose an institutional and political solution that recognizes the powerful forces driving the truck (p. 22).
Looking for a solution to the dilemmas caused by the institutions and practices of psychology and allowing for social change instead of self-vilification, Vivien Burr sees value in “relocating problems away from an intra-psychic domain and into a societal one”. She says that “thinking of oneself as oppressed rather than depressed fosters a different view of oneself and of how to attack one’s problems”. (Burr, 2003, pp. 122 – 125). She too does not attempt to identify ways to “attack one’s problems.”
Like Foucault and Rose, I see psychology as a set of institutions and practices that solve some problems while creating others, whose regimes of truths, and relations of power are under continual contestation. The contest over whether the medical model serves our clients, or serves drug companies, insurance companies, other corporate entities, and governmental forces seeking social control, is waged in many therapy sessions and graduate schools, through argument, lawsuit, prescription, treatment plan, and invoice.