The Paradigm Shift in Psychotherapy: Implications for the DSM

The Paradigm Shift: Definition

Simply defined, the current paradigm shift is the transition from a medical to a nonmedical model of psychotherapy. Over the past two decades, extensive evidence has shown that specific theories and techniques have relatively little to do with effectiveness in psychotherapy and that common factors, and particularly human factors, are the primary agents of change (see, e.g., Baldwin & Imel, 2013; Bohart & Tallman, 2010; Duncan, 2014; Duncan, Miller, Wampold, & Hubble, 2010; Elkins, 2007, 2009a, 2009b, 2012, 2015; Lambert & Barley, 2002; Laska, Gurman, & Wampold, 2014; Laska & Wampold, 2014; Messer & Wampold, 2000; Norcross, 2010, 2011; Stiles, Barkham, Mellor-Clark, & Connell, 2008; Wampold, 2001, 2010; Wampold & Imel, 2015). This evidence undermines the medical model with its assumption that theories and techniques are the agents of change and calls for a new, nonmedical model that reflects the power of human and relational factors. Unfortunately, despite the evidence that undermines the medical model, mainstream clinical psychology in the United States continues to embrace and promote that model. At the same time, however, increasing numbers of psychotherapists, researchers, professors, and students are realizing that the medical model is scientifically problematic. As a result, many are moving from a medical to a nonmedical understanding of psychotherapy and how it works, thus creating the current paradigm shift. In order to understand this shift in more depth, it is important to take a closer look at the old paradigm and the new one.

The Old Paradigm: The Medical Model

The old paradigm of psychotherapy, also known as the medical model, began with Freud, who, as a physician, used a medical schema to describe psychotherapy processes and procedures. Unfortunately, succeeding generations of psychotherapists also embraced the medical model so that today the model dominates almost every aspect of therapeutic psychology, particularly in the United States. (For a more detailed discussion of the medical model and how it has shaped our profession, see Elkins, 2009a, 2009b, 2015.) But what, exactly, is the medical model? Elsewhere, I defined the term as follows:

The medical model in psychotherapy is a descriptive schema borrowed from the practice of medicine and superimposed on the practice of psychotherapy. The schema, including its assumptions and language, accurately describes the processes and procedures of medical practice and has been highly useful in that field. However, the schema does not accurately describe the processes and procedures of psychotherapy and has proven itself to be problematic when superimposed on that field. In medicine, a doctor diagnoses a patient on the basis of symptoms and administers treatment designed to cure the patient’s illness. In psychotherapy, medical model adherents say that a doctor diagnoses a patient on the basis of symptoms and administers treatment designed to cure the patient’s illness. However, when they say this, they are superimposing a medical schema on psychotherapy and using medical terms to describe what is essentially an interpersonal process that has almost nothing to do with medicine. (Elkins, 2009a, p. 67)

In other words, the medical model is a mold borrowed from medicine that forces the processes and procedures of psychotherapy into a medical-like pattern. For example, medical techniques are an integral part of medicine’s regimen of cure. So for more than a century, clinical research, training, and practice, in line with a medical model perspective, have assumed that techniques are the agents of cure in psychotherapy. Only in recent years has it become clear that techniques have relatively little to do with emotional healing, whereas common factors, and particularly human factors, are the primary agents of change. Thus, we are finally realizing that physical healing and emotional healing are not the same. The medical model, which has shaped our profession, is wrong. We need a new model of psychotherapy that reflects the evidence of how emotional healing actually occurs. This is where the new paradigm comes in.

The New Paradigm: A Nonmedical Model

Elsewhere (Elkins, 2015), I summarized evidence from various disciplines to show that humans are evolved to give and receive emotional healing through social means and that psychotherapy is an expression of this evolutionarily derived ability. In other words, humans, who evolved in a social context, are evolutionarily sculpted to heal one another emotionally through human connection and social interaction. Psychotherapy, properly understood, is simply a more intense and focused “subset” of this more general, evolved ability. This means that psychotherapy, as important as it is, has no monopoly on emotional healing. In fact, most emotional healing does not occur in a psychotherapist’s office. Instead, it occurs through supportive connections and interactions with family members, friends, and others. This is not to equate psychotherapy with everyday relationships but it is to say that both draw on the same source of healing—the evolved ability of humans to give and receive emotional healing.

Unfortunately, for more than a century, the field of psychotherapy marginalized the human and relational elements of psychotherapy, viewing them as “nonspecific factors” that had little to do with effectiveness. Now we know that the human and relational elements are, in fact, the most powerful determinants of effectiveness in psychotherapy, dwarfing the effects of theories and techniques. Psychotherapy is an interpersonal process in which human connection and social interaction heal the client’s emotional problems. The new paradigm, in order to reflect this perspective and the evidence that supports it, must place the human and relational elements at the center of psychotherapy and consign theories and techniques to the margins.

Why Understanding the Paradigm Shift Is Important

It is important for clinicians and researchers to understand the paradigm shift because of its revolutionary implications for clinical research, training, and practice (see Elkins, 2015). In regard to this JHP special issue series, understanding the paradigm shift can provide context and guidance as we examine the DSM and explore alternative approaches to describing patterns of emotional distress. The following paragraphs provide specific examples of how understanding the paradigm shift can be useful as we critique the DSM and consider alternatives.

First, the paradigm shift, which is the movement from a medical to a nonmedical model, provides a larger context and more fundamental rationale for examining the DSM and exploring alternatives. The DSM is a medical diagnostic system and a key component of the medical model. If the medical model is scientifically flawed, then it is likely that the DSM, as part of that model, is also flawed. Indeed, it would seem strange to have a medical diagnostic system at the center of a nonmedical model of psychotherapy.

Second, the paradigm shift can provide perspective and guidance as we examine the DSM and explore alternatives. For example, the DSM has many “internal” problems, and while it is important to identify and critique these problems, it is also important that we not become so caught up in critiquing the “trees” that we fail to see the “forest.” The biggest problem with the DSM is not its various internal problems such as problematic diagnostic categories. Instead, the biggest problem is that the DSM is part of a medical model of psychotherapy that has been undermined by contemporary science. This means that the DSM cannot be fixed. It is not salvageable. Even if we were able to fix all the problematic diagnostic categories in the DSM, this would not solve the larger problem. We would still have a medical diagnostic system that is not aligned with the findings of science. This becomes clear only when we understand the larger paradigm shift that is now taking place in our profession.

Third, understanding the paradigm shift can prevent serious mistakes as we explore alternatives to the DSM. For example, some clinicians believe that we should abandon the DSM and use the International Classification of Diseases (ICD; World Health Organization, 2015) instead. At one level, this is appealing. After all, switching to the ICD would undermine the hegemonic status of the DSM and mitigate the power of the American Psychiatric Association, which publishes the DSM, over clinical psychology and other professions that offer psychotherapeutic services. However, from the perspective of the paradigm shift, switching to the ICD would be a serious mistake. The ICD is a medical diagnostic system, very similar to the DSM. Switching to the ICD would contribute nothing to the paradigm shift and could, in fact, obstruct the movement from a medical to a nonmedical model. If we wish to align our profession with the evidence, we cannot replace one medical diagnostic system with another medical diagnostic system. Instead, we must develop a nonmedical approach to describing patterns of emotional distress that reflects the nonmedical character of psychotherapy.

Finally, understanding the paradigm shift can help us appreciate the magnitude of the task before us. This special issue series, which focuses primarily on the DSM/ICD model, is only one battlefront in a much larger war. The “larger war” is the paradigm shift from a medical to a nonmedical model. In recent years, the DSM has been under almost constant fire, especially from clinical psychologists. This special issue series is the latest salvo in that continuing battle. The limitations of the DSM are becoming widely known and thousands of clinicians are deeply concerned. It is likely that the power and influence of the DSM will fade in the coming years. However, as the DSM fades, the most likely scenario is that the ICD will gain increasing influence, becoming the diagnostic system of choice for clinical psychology and third-party payers. In other words, it will be much easier to eliminate the DSM than to eliminate the medical model. Those of us who believe the evidence calls for a paradigm shift must confront the fact that most of the “power centers” of clinical psychology continue to embrace the medical model. These include research centers, training programs, internship sites, psychology associations, and other psychology-related organizations. In addition, the professional reputations and financial well-being of thousands of clinicians, researchers, professors, supervisors, and others are enmeshed, to one degree or another, with the medical model. Because the medical model is held in place by these formidable political and economic forces, we must not be naïve. The medical model will not disappear simply because we reveal its limitations. It will not crumble simply because we present evidence that undermines its scientific credibility. We are in the midst of a revolution, and revolutions, even scientific ones, call for political awareness and action. The paradigm shift is not simply about the DSM; it is about the larger revolution that will be required for our profession to move from a medical to a nonmedical model of psychotherapy.

Conclusion and a Suggestion

This JHP special issue series on the DSM is important. I believe it will become a major reference and source of information for those who have concerns about the DSM. Because of this, it is critically important that we get it right. To “get it right” means that we must focus on the right problems and move forward in the right directions. In my view, understanding the paradigm shift can provide the perspective and guidance we need to accomplish those goals. In line with that perspective, I would like to end this article with the following suggestion: I suggest that we develop a nonmedical system for describing patterns of emotional distress and that we publish this system as an alternative to the DSM and other medical diagnostic systems. Historically, the time is right. Thousands of clinical psychologists, counseling psychologists, marriage and family therapists, licensed clinical social workers, professional counselors, pastoral counselors, and others understand the limitations of the DSM. Although it would take time to develop a nonmedical system and even more time for it to achieve official status, I believe this is the direction that is required. I am acutely aware of the magnitude of the task I am suggesting. I know the formidable nature of the political and economic forces in our own profession that would do everything possible to undermine such an effort. Yet I believe this is the only way to change things, the only way to move forward. Developing and publishing a nonmedical system for describing patterns of emotional distress would (a) contribute to the larger paradigm shift, (b) reflect the findings of contemporary science, and (c) provide a “tangible” alternative to the DSM and other medical diagnostic systems. If we do not develop an alternative system, I suspect we will find ourselves in the position of continuing to criticize the DSM while offering nothing to replace it.

I am honored to be an author in this JHP special issue series. I hope the thoughts presented here will increase awareness of the paradigm shift and contribute to the development of a nonmedical system for describing patterns of emotional distress.