The Great Psychotherapy Debate: Since in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.
In this chapter, Wampold and Imel contrast the Medical Model to a Contextual Model of psychotherapy. The Medical Model argues that there is a biological explanation for a disorder and that the basis for treatment is to address the biological system causing the disorder. Understanding the cause of the disorder (e.g., excess stomach acid) leads to an explanation of the mechanism of the disorder and of change (e.g., reduce stomach acid), which in turn leads to specific interventions (e.g., administer an antacid). Key to this model is specificity: that is, a specific disorder can be explained by a specific mechanism, and a specific treatment based on this explanation will result in alleviation of the disorder. In psychotherapy, for example, one could argue that PTSD symptoms are caused by maladaptive avoidance of traumatic memories, which can be successfully treated by repeated exposure to the traumatic memories to reduce symptoms. Exposure is the specific intervention indicated by the purported mechanism or cause of PTSD. By contrast, Wampold and Imel discuss a Contextual Model of psychotherapy. This model combines the elements of common factors in psychotherapy (e.g., the bond, real relationship, therapeutic alliance) with specific factors of interventions. The Contextual Model indicates that people are fundamentally social animals that require relationships with others to survive and to heal. That is, the initial therapeutic bond between client and therapist is the basis of psychotherapeutic practice. There are three elements to the Contextual Model. (1) The real relationship – which is based on genuineness [openness and honesty] and therapist empathy. Both genuineness and empathy are related to client outcomes. (2) Expectations – which, like the placebo effect, increases one’s readiness to benefit from treatment, is related to greater hope of improvement, and belief in the treatment. The placebo effect is associated with improvements in a pharmacological treatments of depression, and client expectations are related to psychotherapy outcomes. (3) Specific ingredients – as indicated in the Medical Model refers to psychotherapeutic interventions based on a psychological theory of a disorder. But unlike in the Medical Model, the Contextual Model sees the key element of specific ingredients as the agreement between client and therapist on the explanation for the disorder and on the treatment. In other words, a therapeutic alliance in part depends on clients and therapists agreeing on the specific tasks and goals of therapy.