Process Based Therapy: An Introduction

March 26, 2021

“The man who grasps principles can successfully select his own methods. The man who tries methods, ignoring principles, is sure to have trouble.” – Harrington Emerson

Research from psychologist Dr John Norcross estimates that there are over 500 types of psychotherapy.

This can be a depressing statistic to learn about, because there’s no way you could possibly learn them all – at least not in one lifetime.

Moreover, this can leave you with a nagging sense of doubt.

I mean, if there are 500 out there (most of which are “evidence-based”), how you can you be sure that your approach is the optimal one?

What if you’re missing something important?

Luckily, a new pioneering approach to psychotherapy is being developed which offers a solution to this dilemma.

Instead of being a new “brand” of therapy, Process Based Therapy (PBT) is a META approach and overarching framework that can be used in conjunction with all types of psychotherapy, to improve both the effectiveness of treatment, as well as the practitioner’s skills.

In this post, we’ll explore the benefits of PBT, and introduce some of the core ideas of the approach.

#1 – Avoiding “Man with Hammer” Syndrome

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“I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.” – Abraham Maslow

If we are trained in a particular orientation, it can limit our view.

It can lead us to seeing every problem a client has through the lens of our approach. For example, if I’m trained in existential therapy, and a client comes to me with depression, I’ll be tempted to think it might have something to do with problems with meaning in life, and therefore will structure the therapy accordingly. Conversely, if I’m trained in CBT, I’ll consider the depression a result of cognitive processes and will focus on restructuring thought patterns, reducing rumination, etc. Or, if I’m a psychoanalyst, I may see it as caused by things that happened during early childhood development.

The point is, our orientation informs our lens and limits our view. We see the client’s problems from one angle, which may not be accurate, and this can limit our ability to get to the root cause of a problem and provide effective treatment.

A good way to think about this is to consider what it would be like for four blindfolded therapists to try and figure out what an elephant is using their hands.

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The first therapist grabs a tusk and exclaims ‘it is like a spear’. The second, grabbing a leg, says: ‘what are you talking about? It is like a tree.’ The third therapist, who is holding the trunk, argues that it is more like a snake. And the fourth, who has her hand on the elephant’s side, calls them all crazy, and says it is more like a wall.

In psychotherapy, our previous training can have a similar effect.

We see clients’ problems only through one particular lens, which limits our ability both to understand the root causes of a problem, and offer effective treatment for it.

However, when we take a process-based approach, it can help us overcome this limitation, “take the blindfold off”, and see the elephant (i.e. our client’s issue) from multiple different angles.

In short, PBT gives us a holistic, multi-dimensional view of psychological problems.

A Multi-Dimensional Approach

Image credit: Hayes et al., 2020

The ‘Deathstar Project’ is a META analysis of nearly 55,000 studies claiming to have found mediators of change in psychotherapy, carried out by Professor Steven Hayes, Professor Stefan Hofmann, and Professor Joseph Ciarrochi.

Their work has identified that functionally important processes of change can be found in the following six dimensions:

Motivation (what motivates you? How motivated are you?)
Overt Behaviour (actions)
Sense of Self (how do you feel about yourself? How much are you ‘entangled’ with defending a particular type of conceptualised self?)
Attention (what are you focusing on? Can you shift between broad types and narrow types?)
Cognition (what is your relationship to your thoughts? Are you fused with them, or do you have enough flexibility that you can hold them lightly and maintain a bit of distance?)
Affect (how well can you regulate your emotions?)

Typically, a therapist’s orientation will inform which dimension they focus on.

For example, a CBT therapist will focus on a client’s cognition, a psychoanalytic therapist would focus on a client’s sense of self, and a behaviour therapist might focus on the client’s actions.

Thus, previous training causes a bias towards the dimensions that your approach specialises in, at the expense of other, equally important dimensions – where the real issue may lie.

One of the great strengths of PBT is that it provides a framework and methodological approach, which enables therapists to take all six dimensions into account, allowing them to view the situation from multiple angles, and giving them a better chance of figuring out what the ‘root cause’ of what the problem might be.

#2 – Moving Away from The Nomothetic Paradigm

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Since the DSM was first published in 1952, many approaches to psychotherapy have been informed by the ‘latent disease’ model.

This assumes that psychological disorders exist as “latent diseases” in people that you can’t directly measure or assess. Therefore, therapists ask questions to assess symptoms (e.g. rumination), which enables them to make a diagnosis (e.g. depression). Then, they use this diagnosis to find an appropriate treatment protocol (e.g. CBT).

In other words:

Symptom – > Diagnosis – > Treatment Protocol

The nomothetic paradigm assumes that we can somehow cluster people based on arbitrary problems that are defined by ‘experts’ (e.g. the creators of the DSM) that define what these latent diseases are.

There are three major problems with this approach. First, it is disempowering and reductionist for the client, in that it gives them the identity of someone who has a ‘disease’ that they are carrying around. Second, there isn’t any empirical evidence of biological markers for many of these ‘latent diseases’, such as BPD or panic disorder. Third, by clustering clients under broad categories such as ‘depression’, and ‘anxiety disorder’, it takes the focus away from the specifics of their individual historical and situational context, thus reducing treatment efficacy.

In other words, the nomothetic paradigm reduces the individual to a label (e.g. depressed), and assumes standardised protocols can be used to treat all cases of this type.

Process Based Therapy moves away from this nomothetic ‘grouping’ paradigm to an idiographic (i.e. individualised) approach, which treats each client as unique in their own right.

It seeks to honour the complexity of each case, rather than simply labelling someone as having a particular type of disorder, and ‘batching’ them in a particular group.

Good therapists do this intuitively, but PBT offers a scientific framework and training on how to do this.

Using Network Science in Psychotherapy

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PBT adopts a network science approach, and takes the view that psychological problems (e.g. depression) are often made up of many individual sub-problems (e.g. rumination, self criticism, loneliness), which are connected like ‘nodes in a network’.

Each sub-problem that a client comes to therapy with, e.g., “I’m lonely” or “I’m not good enough” exist as individual “nodes” in a network in the mind, and these are linked to others.

For example, a node for “I’m lonely” might be linked with other nodes for “nobody loves me”, “rumination”, and a “history of abuse”.

One of the first stages of Process Based Therapy then, involves the therapist ‘plotting’ this network out, so they have a visual representation of the various sub-problems (nodes) that a client may be struggling with, and the relationships (links) between them.

Image credit: Hayes, 2020

The goal is to figure out which nodes and links you should target to disrupt the network, to turn it from maladaptive to adaptive in a way that serves the client’s values and long term goals.

Crucially, this network-based approach honours the context and complexity of each individual, and moves away from the disempowering, reductionist nomothetic paradigm that sees people as having homogenous ‘latent diseases’ that can be treated with protocols and medication.

#3 – Why the 10,000 Hour Rule Does Not Apply in Psychotherapy

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The “10,000 hour” rule popularised by Malcolm Gladwell in Outliers posits that investing ten thousand hours of practice is enough time to achieve mastery in most domains.

However, research has shown that this finding does not apply in the psychotherapeutic professions.

Why might this be?

To illustrate this, Prof Steven Hayes uses the example of shooting a basketball through a hoop. If you did this day-in-day-out for a few weeks, it’s likely you would see continuous improvements as time went on.

Now, imagine you wear a blindfold and noise cancelling headphones, making it impossible to tell where your shots are landing, and whether or not the ball is going through the hoop.

Would you still see improvements?

It’s unlikely, as you now have no way of knowing if your shots are successful, and therefore no way of making adjustments and improving.

In the same way, psychotherapy, as it is usually practiced, is like playing basketball with a blindfold and noise cancelling headphones on, as the feedback clinicians get is extremely limited.

For example, praise from clients, the duration of therapy, or changes in signs and symptoms.

All of these may depend on other factors. E.g. Clients might stay in therapy longer out of dependence, and offer praise because they have a highly agreeable personality.

PBT offers a solution to this problem in that it involves collecting a high volume of data on each individual client.

A Data-Driven Approach

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“When performance is measured, performance improves. When performance is measured and reported back, the rate of improvement accelerates.” – Pearson’s Law

PBT is highly data-driven in that it requires therapists to collect a high volume of data on clients’ progress, giving them continuous feedback on what’s working and what isn’t.

Earlier in the post, we discussed how process-based therapists draw up a ‘network’ of their client’s various sub-problems (i.e. nodes), and the connections between them, and use this to decide what to focus on in therapy.

At this stage, the therapist constructs a hypothesis about the nature of the problem, and uses this to design an intervention to tackle it.

Then, the client is asked to implement the intervention, and collect a high volume of data specifically related to the problem.

For example, maybe the therapist identifies the client’s self worth ‘node’ is linked with a node for loneliness, and this might be the root cause of the problem. So they create an intervention that targets this (e.g. self compassion meditation exercises), and ask the client to fill out a self report questionnaire once per day, which asks them to rate on a scale of 0-10 of how worthless they feel, and another one which measures loneliness.

This not only gives the therapist feedback on whether the intervention is working or not, it also allows them to take a scientific approach, and test the original hypothesis. If they find it is incorrect, they can now re-draw the network in light of the new data, and construct a new hypothesis and intervention to test it.

Thus, feedback becomes an asset which enables therapists to continuously improve their skills, while simultaneously offering better treatment to clients.

#4 – Reducing Complexity

Magnetic Compass with Needle Pointing Red Principles Word on White Background 3D Illustration

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“Nothing in Biology (or Psychology) Makes Sense Except in the Light of Evolution” – Theodosius Dobzhansky

As mentioned in the introduction, there are over 500 different types of psychotherapy.

Instead of trying to integrate the thousands of different techniques that make up all of these different approaches (which would take at least a few lifetimes), PBT focuses on the core principles that underlie all of them.

To do this, it uses what Philosopher Daniel Dennett argues is the “the single best idea anyone ever had”:

Evolution by natural selection.

Incredibly, evolutionary science offers a framework that can reduce the complexity of all psychotherapies down to six key principles:

Variation
Selection
Retention
In the right context
At the right dimension
At the right level

Let’s briefly look at how each one can be applied in PBT.

Variation

Rigidity is often a root cause of psychological distress; whether its inflexible behaviour or thought patterns. Therefore, a universal ingredient of all effective forms of psychotherapy involves introducing variation. E.g. Varying a client’s thought processes, behaviours, experiences, and the emotions they let themselves feel. Without variation, it’s impossible for change to take place.

Selection

After introducing variation, you now need a process of selection which enables you to keep what’s working, and discard what isn’t. So, after introducing variation, all effective forms of psychotherapy involve a process for reviewing which changes are working to achieve the client’s goals, and which aren’t.

Retention

Once successful behaviours have been identified, you need a way to retain the changes. In psychotherapy, this is often done by creating strategies which help the client to build habits out of the desired behaviour, and by developing new practices and patterns that make it part of their daily routine.

The Right Context

Good psychotherapy will always consider the context of a client’s particular life situation when designing behavioural changes, as behaviour that is adaptive in one situation, may be maladaptive in another. For example, it might be beneficial to recommend more emotional openness to a teenager who attends a nurturing school environment. However, this same recommendation could be harmful, if given to an adolescent who goes to a school with high rates of violence.

At the Right Dimension

Functionally important processes of change can take place in six different dimensions: motivation, overt behaviour, sense of self, affect, cognition, and attention. PBT enables psychotherapists to identify which dimension would be most effective to focus on to achieve the client’s goals.

At the Right Level

Multilevel selection theory tells us that natural selection takes place at multiple levels simultaneously, and that these levels interact with each other. For example, how a client looks after their physiology (sleep, diet, exercise), affects their social relationships and performance at work. Therefore, Process-Based Therapists take both physiological and social/cultural considerations into account when designing interventions.

For any type of psychotherapy to work, all six of these boxes must be ticked.

For example, you can’t select the right behaviours if you don’t introduce variation first. You can’t retain behaviours unless you have first selected what’s working and what isn’t. And it won’t matter if you have all three elements in place, if they don’t fit into the client’s particular context or if you target the wrong level and dimension.

Therefore, evolutionary science principles underlie almost every single effective form of psychotherapy, ranging from psychoanalysis to existential therapy to CBT.

It’s a theory that is so broad and powerful, that it can accommodate almost any therapeutic orientation.

Now that we’ve briefly introduced what Process Based Therapy is, it’s equally important to say what this is not.

PBT is not a new form or brand of therapy.

Instead, it is an overarching framework and META approach which can be used in conjunction with almost any type of psychotherapy, to improve treatment effectiveness and client outcomes.

It has four key attributes which make it particularly powerful in this regard.

First, PBT is multidimensional in that it covers all dimensions where functionally important processes of changes can be found: motivation, behaviour, sense of self, affect, cognition and attention – meaning it helps therapists reduce their blind spots and get to the root causes of psychological problems.

Second, it is a network-based, idiographic approach that honours the complexity of each individual, taking their situational and historical context into consideration, and moves away from the dehumanising ‘latent disease’ model which sees psychological problems as ‘latent diseases’ that people are carrying around which can be treated with protocols and medication.

Third, it is data driven, allowing therapists to continuously monitor the clients’ progress and adjust treatment in light of new evidence.

And finally, it is rooted in the principles of evolutionary science, meaning it takes the key principles of change into account, including, variation, selection, retention, context, at the right dimension and level.

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