Psychology is Changing. This Is What You Need To Know
Is it catching up with reality?
Posted Jun 15, 2020
Clinical Psychology has been shifting paradigms away from a medical model for quite some time. As therapies continue to evolve, it appears axiomatic that the medical, categorical model for protocols is shifting toward an adaptive, evolutionary, and neurologically informed holistic paradigm. But what does all this mean?
This shift means moving away from a strong focus on mental illness as a disease (psychopathology), requiring very specific therapies to treat (like CBT, DBT, or ACT), to the underlying process and mechanisms behind variation, adaptation, and change for a client.
Think of it this way: there are as many models of intervention as there are clinicians. Training and preference for a model will likely dictate beliefs about how to elicit change for a client. However, cutting edge transdiagnostic approaches such as Process Based Therapy move away from "models," or treating a "disorder" found in the DSM-5.
Currently, disorders are thought of as diseases that can be measured by symptoms used to derive a diagnosis such as Generalised Anxiety Disorder, which one uses to treat the accepted symptoms within that disease using their preferred model of therapy. Psychologist Stefan Hoffman argues that this medical model assumes that inevitably a gene or neurocircuitry will be discovered that explains and identifies that particular disorder, and it is only a matter of time before it is discovered.
However, Process Based Therapy1 suggests that instead of looking for biological markers, the clinician focuses on what continues to allow this problem to happen and what are the perceived barriers for change. This includes history and antecedents—notably what, why, and when did it happen. Instead of clustering symptoms to fit a diagnosis, Process Based Therapy accepts an idiographic or individual level approach rooted in clinical science.
Understanding Process Based Therapy (PBT)
PBT is based on Network Science, which focuses on networks and nodes to better understand the presenting problem and the barriers to change in an individual. Imagine a twin cardboard coffee holder, and inside one of the holders is a group of balls, connected by string (the network). Each one of those balls is a node, which can be targeted and attempted to shift or adapt to the next holder by pulling it over the wall and rolling it down into the next holder.
For example “I'm not good enough” may be one such network, filled with nodes that capture this network based on past events, which may be connected in a complex way to “I am lonely” or “I am worthless.” The art of therapy is to work out which nodes one should target to convert from a maladaptive to adaptive behavior (move to the next holder), which nodes can be activated to counter these narratives, and what nodes are preventing this shift in thinking or making goals and working towards one's values.
PBT goes on the assumption that there are two defining features that both help and hinder your recovery; variation and inflexibility. Variation is key to reaching your goals, recovery, and being the person you want to be. Conversely, inflexibility is the core of most emotional distress. Inflexibility is entrenched beliefs and behaviors that are difficult to move. In order to achieve change, the person must be willing to commit to new behavior—otherwise, those balls will slip back into the old coffee holder.
Picture a Slinky
The notion behind this model is an Extended Evolutionary Meta Model (EEMM), which proposes that dynamic, complex networks don't gradually shift or change—they do so dramatically. Networks will attempt to stay stable, adaptive, or maladaptive; when changes occur rapidly, it is labelled catastrophic bifurcation. Networks are resilient to change due to an internal logic keeping the problem in existence—usually around safety or aversion to pain or fear.
The first coffee cup holder is the current adaptive/maladaptive network, while the top of the divide between cup holders is the point of the potential change, in which the individual can fall backward or shift into the new cup holder, much like a penny drop moment or the straw that broke the camel's back. It is sort of like watching a slinky in slow motion as it's pushed of the lip of a stair: The change is small and gradual, as the weight slowly shifts—until it's not, and the whole slinky tumbles onto the next step.
The Glue That Holds It All Together
This meta theory is an umbrella to accommodate evidence-based approaches—not to design a new model, but to unify these models (CBT, ACT, DBT, psychoanalysis, etc.) into the underlying mechanism behind change. The theory suggests the core issues lie within variation, retention, and selection, and that targeting these areas is what the majority of interventions focus on.
For example, diffusion/restructuring, exposure, contingency, shaping behavior, arousal reduction, and mindfulness are all, at their core, providing healthy variation and selection and retention. In PBT, one targets the network with these strategies to turn from maladaptive to adaptive.
Why Do We Need Change?
Broadly speaking, there is a huge list of syndromes and protocols, far too many for a single clinician to become an "expert" in. That's not to mention that many of these disorders often neglect context, which is vital for change. The proponents of this model suggest stepping away from the DSM categorical model. They argue terms such as borderline personality or depression are less important than understanding the network of the individual in context, as well as the corresponding symptoms.
Process Based Therapy allows flexibility in looking at what nodes and networks are maintaining the problem. Instead of focusing on current rumination as a symptom of depression as a CBT therapist, you may be able to pick up on reinforced behaviour of low self-esteem and self-worth issues, which typically a psychodynamic therapist may have picked up on. Strategies can now be used to target self-worth, loneliness, self-compassion, mindfulness, and behavioural changes. You can still tackle rumination or unhelpful behavior, but with an eye to the overall network, and which individual nodes can shift.
The benefit of this node approach is flexibility to adapt sessions based on how the client responds in session. Indeed, the protocol is designed so that the network hypothesis can be redrawn if things are not changing to focus on another network. The goal of the treatment is not to reduce arbitrary symptoms but to move the person toward a different level of experience in line with their value and goals.