What Works and For Whom?
In comparing the medical model and the contextual model of counseling, Wampold (2001) does little to differentiate between which clients seek which model. Availability in providers, referrals, and policy coverage all play an expected role. But could the medical model be more appealing to some clients, while a more contextual model appeal more to others?
The medical model would understandably appeal more to a client seeking more concrete answers. The contextual model would reasonably appeal to the client experiencing their need in more nuanced terms. There appears to be a historical trajectory, following this 4-part cognition cycle:
Nebulous understanding. Something isn’t quite right, and I don’t know what it is. Perhaps my problem is punishment for a wrong choice, and it will simply go away once I make better choices. Or so a generalized sensation may conclude. I go to my trusted faith leader to grope for answers, fearing the worst. Much to my relief, she informs me I am not the only one with this problem as she refers me to a professional counselor.
Modal understanding. Once I learn it has an official label it becomes easier to start looking at is as something apart from my idiosyncratic choices. “The very act of the naming is therapeutic” (Torrey, 1972). “Naming something is the first step toward controlling it” (Frank and Frank, 1991). I can start to differentiate it from my personal experience, and begin to integrate it as something understood by others. A medical construct is often the first step in conceptualizing a shared problem, and more objective responses to it. It’s liberating to realize I am not the only one suffering this malady.
Continuum understanding. In getting a handle on my problem, I start to see shortcomings in those medical constructs. The complexities of my situation spills over the boundaries of those medical constructs. The counselor listens to me process and together we treat those labels more as guideposts in a journey of new discoveries. The therapeutic alliance emerges as a more significant change agent than any particulars of any medical approach. Freed from those walls, I encounter more of the continuum between those labels that are impacting my life. The medical ideal of objectivity now yields to re-integrating the nuanced subjectivity of human experience, shifting focus back to interpersonal agency between counselor and client, between healer and the healed.
Matrix understanding. Not every problem resolves with talk therapy. When exhausting biological and psychological responses, a social dimension to the problem may persist. Not to presume I have given this near as much thought and informed critique as Wampold and others, but my educated intuition informs me that many potential clients are well aware of the social dimensions to their problems. They may avoid a medical model counselor as being implicitly (if not explicitly) stigmatizing. They may be better served by a contextual model, and better served if that counselor segues into some social advocacy. Perhaps they may gravitate to social workers, and even social activism. Something isn’t quite right, and that something is often completely outside of oneself. And no amount of internal change will result in a sustainable remedy to one’s persistent problem.
This occurs to me as a natural progression to redressing the needs of biopsychosocial wellness. Once organic factors are ruled out, we look into the mind of the individual. We consider the particulars in isolation. Initially useful, but their limits emerge. Wellness is not purely biological or psychological. Wellness demands a complementary social perspective.
What if counseling could be rebranded more holistically? The stigma of admitting to having a problem would be mitigated, or dissolved, with the general understanding that counselors will also address the problem’s sociocultural dimensions. What if counseling was generally understood to encourage problem responders to become more collectively involved in social solutions? Could the demand for counseling increase sharply if branded as potentially empowering to collectively redress social conditions that give rise to mental health deficits? Or do we leave that to social workers?
It also occurs to me that common factors enjoy greater impact because, in part, it creates a secure psychosocial environment for processing in microcosm the needed psychosocial balance in the client’s daily life. Therapy itself is less of a change agent as the therapeutic relationship that creates a proxy environment for exploring and addressing psychosocial deficits in a client’s routine relationships. Such deficits could well be a routine artifact of civilization, of increased specialization of labor with normative alienation.
It is my contention that no sustainable wellness can occur without psychosocial equilibrium, grounded upon reliable physiological wellness. This requires the necessary material and emotional/social resources. The implications this has upon our politics, economics and need for justice is something I look forward to exploring in the blog entries ahead.
Torrey, E. (1972). What Western psychotherapists can learn from witchdoctors. American Journal of Orthopsychiatry, 42, 71.
Wampold, B. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Erlbaum. Chapter 9: Implications of rejecting the medical model (pp. 203-231)