Psychology
Process-based psychotherapy
Abstract
The science of psychology has a renewed interest in human subjectivity and mental health — termed as process-based interventions — due to increasing recognition of shortcomings with its current materialistic model. This article provides a critique of the materialistic approach, a look at current and past understanding of process in psychotherapy and further elucidates what process actually is, along with providing examples of approaches for psychotherapy.
New innovations in the science of psychology have begun to identify the importance of process (i.e. focusing on the individual’s unique subjective contributions to their mental illness) in psychotherapy (1), though the idea is still in its very nascent stages. Nevertheless, this is a positive sign for psychology and psychiatry as, in recent decades, the fields have become almost exclusively focused on identifying specific treatments and specific brain chemical deficiencies for specific mental disorders (2). This has not worked out as the field had hoped as decades of funding and research have not supported this materialist-first approach (3). As such, the new trend at hand may be ushering in a renewed focus on human subjectivity and complexity, which has the potential to move the field away from a strictly materialistic focus and to begin to identify the deeper aspect inherent in each human being. But then, the question arises of how does a psychotherapist go about implementing a process-based approach in practice, especially when it is still being defined? And what would be the benefits of a process-based approach to the client of the psychotherapist? Before we answer these questions, let us further explore the shortcomings of the current materialistic viewpoint.
The materialistic viewpoint
Issues are rife with the materialistic viewpoint currently prevalent in psychology and psychiatry, particularly in the United States. For instance, the current viewpoint is fatalistic in nature as it views humans as entirely at the mercy of their brain chemistry and genetics, thus limiting one’s perceived power to modify and overcome their nature. The current viewpoint is also quite simplistic and overly-rational as it proposes that Problem A can be resolved by Solution B, thus losing the unique individual experience and complexity of each human and further making clients dependent on ‘experts’ for solutions, rather than fostering the clients’ own capacity for psychological growth. Lastly, the current viewpoint has failed to identify the deeper processes that underlie psychological growth: mainly one’s increased self-awareness (4, 5) and meaning making (i.e. using challenges in life as an opportunity to learn about and change oneself) 1.
The present materialistic viewpoint in psychology is a reflection of American culture in general, which tends toward gross materialism and seeks solutions through material innovation and systems. More specifically, American culture believes that material objects and technologies must be innovated for people to develop, having yet to see that humans themselves can change and innovate. Of course, the latter is only that which would lead to a true change in the individual and, subsequently, the society.
Despite ample research to the contrary, the current materialistic view has been fomented by the commercial aspect of American society in its seeking for money as part of its world-dominant capitalistic model. For example, as recently as 2008, pharmaceutical companies spent approximately $20.5 billion on marketing alone in the US for their drugs, $15.7 billion of which was spent directly on physician detailing (i.e. having sales representatives directly provide physicians with free samples, gifts, meals, etc.) (6). Furthermore, illustrating the undue influence of these marketing strategies, physicians who practise in states where marketing has been restricted, prescribed new mental health medications less frequently, especially when gift-giving was banned (where reductions ranged from 39% to 83%) (7). While medication for psychological disorders certainly has its place, it appears to have been seized by the reductionist rational mind and collective vital of the field for its own benefit. Process-based psychotherapies may one day be an antithesis to this.
Already existing process-based views
As mentioned, research does exist demonstrating the importance of process — or a turn towards human subjectivity and complexity — in psychotherapy. For instance, a large body of research has shown for some time that there is no difference in effectiveness between different types of psychotherapies (8) and that one of the best and most consistent predictors of psychotherapy outcomes is actually the therapeutic alliance (i.e., the strength of the relationship between the client and the psychotherapist) 2 (9). Furthermore, dating back to the 70s, Carl Rogers (a pioneer in psychotherapy and psychotherapy research) identified that the goal of his theoretical approach was to help clients move toward becoming more process-oriented with their internal experiences, rather than seeking simplistic logical and rational conclusions (10).
Process-based psychotherapy implementation
Now, we shall return to the questions of: How does a psychotherapist go about implementing a process-based approach in practice, especially when it is still being clearly defined? And what would be the benefits of a process-based approach to the clients of the psychotherapist? Process-based approaches should strive to be collaborative (i.e., the psychotherapist and client are equal holders of power), client-centred (i.e. permit the client to define their own goals, feelings, etc.), process-based (i.e. questions that enquire about what is happening right now, rather than too much about the past), and ultimately focused on creating self-understanding. This last element of creating self-understanding is particularly critical as it has the capacity to empower the clients to be active participants in their psychological growth, even once the therapeutic relationship has ended. To use an analogy, helping clients learn how to introspect and understand themselves, rather than providing them superficial solutions, is the difference between teaching a drowning person how to swim versus throwing them a liferaft.
Examples of questions that help clients introspect, and subsequently witness, evaluate, and refine their psychological nature, follow:
When dealing with disharmony or conflict within the personality
• On the one hand you feel X (e.g., wanting to do something new), and on the other hand you feel Y (e.g., you do not want to change). How do you deal with this conflict?
• How can you get different parts of your personality to work with each other? Or do you prefer to keep things the way they are now?
When dealing with negative patterns in emotion or thought
• How do you recognise when X (e.g., anger, anxiety, self-criticism) is occurring within you?
• How can you recognise this earlier?
• What makes you not notice until X occurs (e.g., the next day)?
• Would you like to respond to this differently when you see it arising within you? If so, how?
• How are you right now as a person and how would you like to be in the future? What do you need to do to get yourself there?
• (When the client has made a positive change) What did you do internally to bring about that change so it can be recreated?
When attempting to make an important decision
• How do you go about making decisions for yourself?
• What is getting in the way of you making a decision for yourself?
• Have you ever been successful at making decisions in the past? If so, can that be applied here?
When dealing with the Interpersonal dynamic between the client and therapist
• I notice that you sometimes do X (e.g., laugh, get silent, become distant) when we begin to go deeper. What happens for you in those moments?
• What is the function of this (i.e., what is the purpose or reason of its existence)?
• Are you satisfied with the way you currently are in here? If not, how would you like to be different?
• Is the way you are in here similar or different to other areas of your life? If so, how and why?
When addressing cultural factors
• Do you feel that any aspect of your identity (e.g., race, ethnicity, gender, age, disability status, religiosity, residency status) may be playing a role in what is currently going on for you?
• Does me being X (e.g., a male) contribute in any way to the way you are currently feeling or expressing yourself in here?
Conclusion
As can be seen, a process-based approach is largely comprised of here-and-now, open-ended questions that are supposed to help the client learn how to introspect, thus eventually situating the growth process within them, rather than the psychotherapist. Furthermore, asking questions in this way still allows the psychotherapist to be guided by their respective theory, while permitting the client to define and identify — in their own terms — what is causing their current difficulty, thus increasing its meaning. This type of approach has the capacity to help clients get in touch with the central stable witness aspect of their personality, rather than the constantly fluctuating set of ideas, emotions, impulses, and bodily sensations in their surface nature.
References
1. Hoffman S, Hayes SC The future of intervention science: Process-based therapy. Clinical Psychological Science 2019; 7(1): 37-50.
2. Ibid.
3. Ibid.
4. Dalal AS. Psychology, Mental health and Yoga: Sri Aurobindo’s Psychological Thought Implications of Yoga for Mental Health. 2nd ed. Pondicherry: Sri Aurobindo Ashram Press, 2001, p. 45.
5. Sen I. Integral psychotherapy: Approach and standpoint. Psychological Research Journal 1984; 8(1-2): 55-61.
6. King M, Bearman PS. Gifts and influence: Conflict of interest policies and prescribing of psychotropic medications in the United States. Social Science Medicine 2018; 172: 153-62.
7. Ibid.
8. Wampold BE. The research evidence for common factors models: A historically situated perspective. In Duncan BL, Miller SD, Wampold BE, Hubble MA (eds.). The heart and soul of change: Delivering what works in therapy. 2nd ed. Washington, DC: American Psychological Association; 2010, pp. 56-60.
9. Hubble MA, Duncan BL, Miller SD,Wampold BE. Introduction. In Duncan BL, Miller SD, Wampold BE, Hubble MA. (eds.), The heart and soul of change: Delivering what works in therapy. 2nd ed. Washington, DC: American Psychological Association; 2010, p. 37.
10. Meador BD, Rogers CR, Person-centred therapy. In Corsini RJ. (ed.), Current psychotherapies. 2nd ed. Itasca, Illinois: F. E. Peacock Publishers, Inc.; 1979, pp. 164-66.
1 Note that this is an initial form of ego destruction, as one uses life’s challenges to identify their own deficiencies, rather than expecting the circumstances of life to change in order for their suffering to cease.
2 Interestingly, the therapeutic alliance is also predictive of outcomes in different types of therapies, including psycho-pharmacotherapy.
Dr. Christian A. Latino obtained his PhD in Counseling Psychology at the University of Iowa and currently practises as a therapist at the University of California, Davis in the USA.
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