From technique-based to process-based
On what may change in our work when we think in terms of active processes instead of protocols.
A gradual shift seems to be underway in the way we look at psychotherapy. For decades we have bundled techniques into protocols, which we applied to specific disorders: CBT for depression, EMDR for PTSD, schema therapy for personality problems. It is an orderly system, and it has brought a great deal of good.
At the same time, it became clear that the system does not entirely add up. Many protocols work about equally well for different disorders, many patients also improve with the "wrong" therapy, and within a single protocol what works for whom often differs considerably. The link between protocol and disorder proved less solid than had been assumed.
What remains when we look beyond the protocol?
The question is increasingly being asked, by Steven Hayes and Stefan Hofmann among others, which active processes are at work in all these different therapies. And whether we can direct our interventions at those processes, rather than at the techniques in which they are packaged.
The list of such processes is still being developed, but there is by now a reasonable degree of agreement among researchers. Those mentioned include attention regulation, cognitive flexibility, acceptance and defusion, values clarification, behavioural activation, social reconnection, body awareness, emotion regulation, mentalising, self-compassion and meaning-making.
What stands out is that these processes are not disorder-specific. They appear to play a role in depression, anxiety, personality problems and trauma, not always to the same degree or in the same combination, but as an active ingredient behind very different protocols.
"Working with complex systems calls for trial and error, creativity and responsiveness. Not as a weakness, but as a fitting response to a system that cannot be nailed down."
What might change?
Suppose that in training we no longer mainly learned which protocol belongs to which disorder, but which processes are active and how they can be supported. That would shape the psychotherapist of the future in a different way.
Instead of carrying out a protocol, she would then learn to examine with each patient which active processes are being underused. For one patient that is attention regulation (she is caught up in rumination), for another values clarification (he no longer knows where he wants to go), for a third behavioural activation (she has come almost to a standstill).
The interventions then come from a broader repertoire: sometimes classical CBT, sometimes ACT, mindfulness, motivational interviewing or EMDR, and sometimes a conversation about what could give her life meaning. The instrument then follows the active process, and not the other way around.
Three changes in the consulting room
First: more listening, looking for longer. In process-based work it is not immediately clear which processes are being underused. Listening therefore comes first, not in order to complete a case history, but in order to see what is needed here. It may take two, three or four sessions before the picture becomes clear. In our view that time is not lost, but part of the work.
Second: more dialogue, less delivery. An announcement such as "today we are going to do cognitive restructuring" fits well within a protocol, but less well within a process-based treatment. There the patient thinks along: which processes help her, and which interventions fit what she wants to achieve? Treatment thus becomes more of a joint inquiry than the delivery of a service.
Third: more attention to timing. Which active processes are best engaged depends on where the patient stands now. Someone who has only just been able to acknowledge her trauma needs different work from someone who has been in treatment for it for three years. And someone who may be close to a tipping point (which early warning signals may indicate) calls for different attention from someone standing on stable ground.
What process-based work is not
Process-based work is not eclecticism in the sense of "we do what feels right". It rests on a growing empirical basis concerning active processes in psychotherapy, and it calls for systematic thinking about which processes work where, and why.
Nor is it a rejection of protocols. Many protocols are in fact careful combinations of active processes, for a specific group of patients in a specific phase. If a protocol suits this patient, there is every reason to use it. It only becomes difficult when we apply it because it belongs to the disorder, while in this patient other processes are being underused.
Neither does it mean that structure becomes superfluous. Therapy needs structure, for the patient and for the clinician. It is just that this structure then arises from the active process, and less from a fixed series of sessions.
To begin with
For those who are curious about this, we see three possible first steps.
One: an accessible entry point is Process-based CBT (2018) by Hayes and Hofmann, or the shorter Beyond the DSM (2020).
Two: it can help to start with one patient for whom the existing protocol yields little, and after each session to consider which active processes were supported and which were left aside.
Three: it is pleasant to do this together with colleagues. Process-based work asks for more thinking of one's own than working according to a protocol. A peer supervision group in which cases are discussed from this framework is, for many people, a good way to grow into it. (For that reason there are also groups on this platform; more about them under Activities.)
The move from technique-based to process-based work is, in our view, a recalibration rather than an upheaval. In a sense it connects with what experienced clinicians often already did, but now better grounded, more transferable and easier to research. It may be one of the most tangible ways in which complexity thinking can influence the work in the consulting room.