Imagine that you are a prospective client seeking psychotherapy services for the first time. You obtain free consultations from two therapists who proceed to inform you of their approach after you’ve shared a bit about your reasons for seeking therapy.
Therapist A explains that they specialize in treating your primary complaint by employing a standardized evidence-based protocol that would involve you going through a step-by-step set of procedures to work towards resolution of your symptoms. For any other issues (i.e. disorders) that present themselves during the course of treatment, Therapist A may refer you to other specialists who treat these (seemingly) separate conditions.
Therapist B, on the other hand, advises that they take a personalized approach to therapy that targets the specific processes that give rise to and/or maintain your particular issues. They note that their treatment approach may naturally change over time, and look different from one session to the next, depending upon your evolving needs, goals, and treatment responses. And, as opposed to a primary focus on symptom-reduction, Therapist B’s process-based approach has a dual aim of alleviating your suffering more broadly while advancing your overall wellbeing.
If we were to imagine these two therapists as musicians, the evidence-based approach might entail Therapist A learning, note for note, a set of well-known and well-regarded songs that they would then perform for you, whereas Therapist B would be collaboratively writing songs with you based upon their working knowledge of music theory and your specific taste in music.
Which of these two therapists would you choose and why?
The first option (Therapist A) employs a more traditional “one size fits all” medical model whereas the second option (Therapist B) is derived from the developing understanding that there is “no one size fits all” approach to mental health. While we all share our common humanity, we are also individuals with unique and evolving biopsychosocial circumstances and needs that call for a more nuanced approach to health and wellness. And, recent studies have begun to bear this out:
A randomized controlled trial examining the effects of a self-help app on anxiety, depression, and stress with 69 adults found that tailored skill coaching based upon in-the-moment psychological experiences outperformed both a random application of the app and one that strictly did assessment (Levin, Haeger, & Cruz, 2019).
Two meta-analyses, with over 10,000 total participants (both adults and adolescents), found personalized interventions to be superior to standardized interventions (Li, et al. 2024; Nye, et al. 2023) with findings from one suggesting that “rather than targeting personalization on a larger scale such as selection of which therapy modality or treatment package to use or the intensity of treatment, personalization on a smaller scale targeting the components or kernels of an intervention may be more effective at improving treatment outcomes” (Li, et al. 2024).
Relatedly, there’s emerging evidence suggesting that process-based interventions, such as mindfulness and compassion, once thought of as universally beneficial, are not helpful to everyone (Sahdra, et al. 2023), and may be most effective when applied in the right context, such as targeting experiential avoidance with acceptance (Levin, Haeger, & Cruz, 2019).
In light of this, how might clinicians approach their work with clients?
Hayes, Hofmann, and Ciarrochi (2020) suggest being guided by the following question: “What core biopsychosocial processes should be targeted with this client given this goal in this situation, and how can they most efficiently and effectively be changed?”
While there are different ways that a clinician could go about answering this question, one method is in assessing here-and-now processes that arise during sessions and then intervening directly on those processes. These processes can be found in the sequence of events, or stimulus-response interactions, that clients exhibit and describe.
So, for example, a client shares, “I’m constantly worried about my health and contracting a deadly disease. So, I don’t socialize anymore.” From the perspective of acceptance and commitment therapy (ACT), this behavioral description may be indicative of a process called “cognitive fusion” in that the client’s response to worry is resulting in it having a dominating influence over choices. Or, a client declaring, “I want to be more present with my children; I want to convey that their very existence matters to me,” would denote a process of valuing in that the client wants to respond to a stimulus in a desirably meaningful way. With the former example, we may aim to undermine the fusion (especially if socializing was important to the client), whereas in the latter scenario, we may want to augment values-based functions and/or invite the client to consider how they would engage (act upon) this value with their children.
Detecting when, and understanding how, these processes occur in therapy can support clinicians in being more timely, person-centered, and effective in their interventions.
This type of training can be found in my live-online Advanced ACT course where we make use of a user-friendly coding form called Flexibility Across Dimensions (FAD) to assess and target processes across six psychological dimensions: emotion, cognition, attention, motivation, self, and overt behavior. For example, a client’s verbalized behavior of “I constantly doubt and criticize myself, but I’m still able to do what I need to do,” could be coded for both inflexible and flexible processes within the dimensions of self, cognition, and overt behavior.
While we’d want to hold lightly such isolated functional assessments, and stay sensitive to the larger context surrounding a given behavior, the FAD can reveal certain process-based trends occurring over the course of a session that may warrant closer attention and further analysis.
And, beyond working directly with the biopsychosocial processes of a given individual or couple (or group for that matter), we can personalize our approach to therapy by taking a vested interest in our client’s deeply held desires and emotional vulnerabilities – parts of them that may not typically have a voice or an attentive non-judgmental audience.
Questions, such as “What is that (painful feeling) like for you?” and “What do you long for?”, can convey that one’s lived and longed for experiences matter to us; that there is no one size fits all model that can effectively speak to such idiographic variables nor adequately address any suffering and wellbeing that arise from them.
If we can stay curious and open to each client’s expressions of hurt, care, fear, and yearning, while attuning to specific processes instead of attempting to fit everything they say and do into a neat little box (i.e. diagnosis) or treatment formula, then we are more likely to meet our clients where they’re at and intervene in ways that support their personal growth.
References:
Hayes, S. C., Hofmann, S. G., & Ciarrochi, J. (2020). A process-based approach to psychological diagnosis and treatment: The conceptual and treatment utility of an extended evolutionary meta model. Clinical psychology review, 82, 101908.
Levin, M. E., Haeger, J., & Cruz, R. A. (2019). Tailoring acceptance and commitment therapy skill coaching in the moment through smartphones: Results from a randomized controlled trial. Mindfulness, 10, 689-699.
Li, W., Gleeson, J., Fraser, M. I., Ciarrochi, J., Hofmann, S. G., Hayes, S. C., & Sahdra, B. (2024). The efficacy of personalized psychological interventions in adolescents: a scoping review and meta-analysis. Frontiers in Psychology, 15, 1470817.
Nye, A., Delgadillo, J., & Barkham, M. (2023). Efficacy of personalized psychological interventions: A systematic review and meta-analysis. Journal of Consulting and Clinical Psychology, 91(7), 389.
Sahdra, B. K., Ciarrochi, J., Fraser, M. I., Yap, K., Haller, E., Hayes, S. C., … & Gloster, A. T. (2023). The compassion balance: Understanding the interrelation of self-and other-compassion for optimal well-being. Mindfulness, 14(8), 1997-2013.