In the increasingly competitive market place of mental health providers, where do we, the humanistic/existential psychologists (HEP), position ourselves? With positive psychotherapists and happiness coaches gaining grounds in the domain of personal growth, and neuroscientists and mindful meditation dominating the field of spirituality, in what areas can we stake out a claim of being a major player? What are the compelling characteristics of our brand of psychotherapy?
These questions swirled in my head as I pondered over David Elkins’s (2009a) provocative article. Basically, I agree with Elkins’s case against the medical model and his critique of the restrictive and biased nature of evidence-supported treatment (Elkins, 2007, 2008). I can also fully understand his displeasure toward the health insurance industry. But here is our conundrum: We may be right on psychological, therapeutic, methodological, ethical, and moral grounds, but we still fail to gain wide acceptance by mainstream psychology. The challenge confronting us is how to overcome this barrier without compromising our core convictions.
I differ from David more on matters of strategy and stance than substantive issues. For both pragmatic and theoretical reasons, I prefer a more open and integrative stance in the spirit of Kirk Schneider’s (2008) existential-integrative psychotherapy. We also need to develop a new coordinated strategy to fulfill the mission of HEP. Elkins’s article is like a clarion call to the faithful to make personal sacrifices and defend the truth: “This time the revolution would involve rejecting the medical model, breaking away from the medical establishment, and telling managed care and the health insurance industry that we will no longer require their services” (p. 83).
But I question whether we can gain many converts and supporters by defining ourselves in terms of what we are against rather than what we are for. We need a positive and compelling narrative to reignite a new interest in HEP.
In some ways, we may be victims of our past success. We are unable to free ourselves from the powerful language and theories of the humanistic/existential luminaries from the 1960s. We are so struck by awe and reverence that we dare not deviate from their writings. As a result, we look backward rather than forward, and we remain long on high-flying ideas but short on research.
Questions That Demand Answers
Elkins’s article has triggered a number of critical questions that demand thoughtful answers from leaders of HEP. The following questions quickly jump to mind:
- Do we have a clear and compelling vision of HEP for the 21st century?
- What are the new ideas, new theoretical developments, and new empirical findings in HEP in the past 10 years?
- Do we have any coordinated systematic research programs inspired and guided by HEP?
- Do we have any consensus regarding the right kinds of outcome measures we need to establish the efficacy of humanistic-existential psychotherapy?
- Do we have any systematic research to develop reliable and valid tools to measure the outcomes of humanistic-existential psychotherapy, such as acceptance of existential givens and the experience of inner peace and freedom?
- Why can’t we learn something from positive psychology, which has spread like wild fire with its scientific vision of authentic happiness, personal growth, and meaning in life—the three core themes of HEP?
- Why can’t we learn something from positive psychotherapy, which has quickly established its efficacy of this strength-focused approach through manualized, mechanized, and linear short-term online interventions (Seligman, Rashid, & Parks, 2006; Wong, in press-a).
These questions call for self-reflections and open-minded inquiries. We need to put our heads together and come up with good answers to these probing questions regarding HEP’s future directions in research, training, and development. It would be more profitable to think along these lines rather than fighting the same old battles.
An Alternative Strategy
Between the extremes of marrying someone and severing all relationships, there is an alternative strategy of coexistence and cooperation at varying levels as the situation demands. In other words, for pragmatic reasons, we can work with the medical model as we have to with many of the imperfect social institutions such as different levels of government. We need to accept imperfect realities because we will never live in an ideal world.
Here are some of the examples of productive alternative approaches. The Houston Galveston Institute is internationally recognized for its innovative collaborative approach to the advancements of theory, research, and psychotherapy practice. The Taos Institutes seeks to enhance the well-being of individuals and society through the application of social constructionist ideas and appreciative inquiry with special attention to organizational development and family therapy. Both these organizations focus on their own research and objectives without seeing the need to attack the medical model.
Similarly, the International Network on Personal Meaning, an organization started by me 10 years ago, is dedicated to advancing health, spirituality, peace, and human fulfillment through research, education, and applied psychology with a focus on the universal human quest for meaning and purpose. The International Network on Personal Meaning sees meaning as a natural point of intersection between the humanistic-existential tradition and the positive psychology of meaning (Tomer, Eliason, & Wong, 2008; Wong, 1998, Wong, in press-b). The above examples illustrate an alternative strategy of moving forward with a clear vision of research and therapy way beyond the restrictive confines of the medical model without attacking it directly.
The War Against the Medical Model Is Unwinnable
Elkins’s critique of the medical model is directed against the APA (Elkins, 2009b) and clinical psychology (Elkins, 2009c). Implicitly, it is also a critique against the scientist-practitioner model of clinical psychology. His combative rhetoric places us in a bind: How can we both seek acceptance by mainstream psychology and relentlessly attack it at the same time?
There are many reasons for the hegemony of the medical model of mental illness. It will continue to dominate mainstream psychology in spite of widespread criticisms (Jesen, 2009; Laungani, 2002; Linley & Joseph, 2004; Joseph & Linley, 2006; Wampold, Ahn, & Coleman, 2001). As long as medicine and science remain the most credible and trusted social institutions without any viable alternatives, the medical model will continue as king of the hill. Positive psychology has mounted a more effective challenge against the medical model than HEP because of its emphasis on scientific research (Duckworth, Steen, & Seligman, 2005). However, the war against the medical model is not winnable, at least not in the foreseeable future.
The Ethical Issue of Practicing the Medical Model
Toward the end of his article, he seems to frame the issue as an either-or choice: Either reject the medical model completely and suffer financial consequences or compromise our professional lives and “play the game” to get insurance reimbursement. He makes an ethical argument in favor of rejecting the medical model. Elkins argues that the medical model obscures the fact that psychotherapy is an interpersonal process rather than a medical procedure to treat mental disorders; therefore, we must consider the ethical implications of pathologizing the clients with a “mental disorder” when they simply seek support and guidance in their struggles with the predicaments of life. I propose that this ethical issue is actually a straw man for the following reasons.
First, McCready (1986) has long pointed out that there are varying degrees of adherence to the medical model. The extreme kind may “include unequivocal subscription to the disease model of emotional disturbance, a paternalistic hierarchy of providers, narrowly defined treatment parameters, nosological obsessions and nomothetic paradigms” (p. 1).
Elkins has clearly adopted a very strong and narrow definition of the medical model. I wonder how many clinical psychologists fully embrace this strong definition and apply the disease model to explain and treat emotional and behavioral problems brought on by poor coping skills, stressful events, and relational deficiencies. Most clinical psychologists take a more pragmatic approach. They will use the Diagnostic and Statistical Manual of Mental Disorders (DSM) classification as one of several assessment tools within the context of interpersonal therapeutic conversations. To diagnose someone as “depressed” does not necessarily mean that the client is pathologized as long as the client is treated with empathy, unconditional positive regard, and genuineness as a unique human being (Rogers, 1957).
Second, I also wonder what percentage of clinical psychologists really experience “professional guilt” simply because they are working with clients who are not mentally ill. Most clinical psychologists routinely work with cases of adjustment, personality, and relational problems, which are recognized by DSM. Furthermore, personal struggles often involve depression and anxiety as a concomitant. Many employment assistance programs (EAPs) will reimburse through third-party insurance for treating work stress and all kinds of real-life problems cited by Elkins. I also know that many clinical psychologists, including myself, offer their services to those who cannot afford it pro bono or through a sliding scale. The only clinical psychologists who should experience professional guilt are those who bill the insurance company for their services but do not have the skills to really help their clients.
Elkins (2009a) wrote the following:
It is honorable to help those who are struggling with the difficult problems of life or who come to therapy because they want to become better human beings. There is so much pain and lostness in the world that we should never denigrate those who dedicate their lives to giving comfort, support, and guidance. (p. 82)
Honestly, I am really puzzled by his emphasis. Most psychologists, especially those with a narrative, positive, or humanistic orientation, do try to help their clients become healthy and happy human beings. I am even more puzzled by the suggestion that some clinical psychologists “denigrate” those who dedicate their lives to providing support and guidance to their clients. Does he refer to a professional rivalry between clinical psychologists and life coaches? That would be a different issue.
As an existentially oriented clinical psychologist, I don’t think there is anything unethical or compromising to bill insurance companies for helping people with relational and adjustment difficulties not caused by genetic or physiochemical processes. In fact, the very term psychotherapy already has the connotation that we are trying to help clients struggling with some mental, emotional, or behavioral problems through talk-therapy, which is basically interpersonal.
In sum, we do not need to face the ethical dilemma of either totally rejecting the medical model and suffering financial loss or embracing an “inaccurate and problematic system” with guilt feelings. I seriously question the wisdom of opting out of insurance coverage for HEP-based psychological services purely on ideological grounds. Receiving third-party payment for helping clients with adjustment difficulties does not imply buying into the medical model. Elkins’s interpretation of the medical model would have us backed into a corner without much future. If most humanistic/existential psychotherapists should limit our serves to areas of support, guidance, and personal growth, then, we are no different from life coaches and career counselors.
We are living in a troubled age and a broken society. What can we do to contribute to develop a culture of respect, compassion, and tolerance in the face of radicalization and fundamentalism? What can we do to find effective ways to overcome and transform the dark side of the human condition such as violence and atrocity against other human beings? How do we instill meaning and hope in those struggling in the dark valleys of pain, illness, and death? How can we encourage and empower people in their struggle with the universal, existential givens? How do we cultivate a sense of awe and appreciation toward the gift of life?
I believe that more than any other theoretical orientation in psychology, HEP is uniquely suited to rising to the above challenges. Indeed, we have a great deal to offer to advance psychotherapy and better humanity in so many domains. We have inherited a great treasure, full of profound insights and noble ideals about human existence. We are sitting on the shoulders of giants such as Rogers, May, and Maslow. We alone have taken it as our mission to wrestle with the really important big questions confronting individuals and society.
In many ways, I admire Elkins’s passion for HEP, which reminds me of another “hardy warrior”—an endearing title given to Carl Rogers by Yalom in Rogers (1980). But the impact of Rogers does not come from his battle with behavioral psychology and the medical model. His groundbreaking therapeutic approach gains wide acceptance because it is buttressed by decades of solid empirical research (Patterson, 1984).
Why has HEP lost its influence not only in psychology but also in society in the last three decades? Elkins (2009b) concludes that our decline is because of the inherent incompatibility in values and assumptions between HEP and the mainstream psychology. There is some truth in Elkins’s analysis. But I think a big part of the problem is that HEP has not caught the vision of taking a more positive and cooperative stance toward the medical model and scientific research. Our challenge is to make HEP a positive force for change not only in the field of mental health but also in a broken world.
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Wong, P. T. P. (2010). The future of humanistic/existential psychology: A commentary on David Elkins’s (2009a) critique of the medical model. Journal of Humanistic Psychology, 50(2), 248-255. https://doi.org/10.1177/0022167809355432