In the evolving world of mental and behavioral health, the winds of change are blowing towards a more individualized, process-focused approach. Let’s explore together what a mental health landscape might look like if we shift our focus from categorizing people based on DSM disorders to understanding and modeling the “processes of change” that empower or interfere with our life journeys.
#1 Broadening the Scope of Practice
Traditionally, mental health practitioners have often focused on so-called “disorders” like “major depression” often becoming inattentive to more specific, changeable, and interconnected issues such as loneliness or the lack of human connection. Loneliness is not just a “sign” of something – it is something! It’s shocking how many problems have been minimized and given far less attention than they deserve, because of the horse blinders our mental health system forces on us all in its futile search for hidden mental diseases.
By adopting a process-focused approach, practitioners can address a wider range of problems in a coherent way. Core processes that contribute to one problem often relate to others, which means that a more holistic understanding of mental and behavioral health gives people actual tools they can use over and over again. If a practitioner is helping a client with, say, anxiety struggles, why not also help with their distress from tinnitus, or the impact of back pain, or habits like biting nails until their fingers hurt, or problems in communication with loved ones?!
Often the same processes of change apply to all of these areas, and it’s not like there are scores of other professionals out there ready to step in problem by problem. Technology and apps will play a crucial role in this transformation, enabling practitioners to extend their reach and to efficiently address a broader spectrum of issues. Go ahead and address the anxiety issue, but as process-based skills are acquired, let’s give clients the information about how to apply these same principles to the ringing in their ears, for example.
#2 Emphasizing Social Context
A key shift in this new paradigm is the emphasis on the social context of clients. Mental health is not just an individual issue; it’s deeply embedded in social interactions and environments. Understanding a client’s difficulties within their social context needs to become a vital component of therapy. It’s much easier to do when you are asking questions about context and allowing modern statistical tools built on AI to root out connections. A recent meta-analysis of ecological momentary assessment data showed that just being with other people (data we can now easily get from a person’s smartphone) predicted positive affect. We can use knowledge like this to not only enhance treatment effectiveness but also foster a deeper, more empathetic understanding of the individual’s experiences.
#3 Moving Beyond Traditional Psychometrics
The process-focused approach advocates for a departure from traditional psychometrics and their unwarranted reliance on consistencies across people instead of regularities within people over time. Instead of bell curves and their false promise to predict the trajectories of our lives, we need to focus on tracking individual progress or deterioration over time, learning how these trajectories are impacted by how a person deploys processes of change. Every client’s journey is unique, and standardizing experiences on a bell curve overlooks this crucial fact. Furthermore, that very effort is based on statistical assumptions that we know are false. If we want every voice to matter, we need to learn to listen to our clients and to learn from them. The kind of listening and learning we most need includes measuring and modeling their specific paths. The days of turning people into statistical “error terms” need to end.
#4 Rethinking Diversity, Equity, and Inclusion
The new focus on processes of change will enable us to approach diversity, equity, and inclusion more effectively. We know it’s wrong and dehumanizing to try to force fit individuals into mainstream norms. It’s similarly risky to simply create new sets of norms under specific labels. A better pathway is to work with stigmatized groups to help develop tools that appreciate and address each person’s unique experiences and challenges, in the context of crucial social and cultural information. This approach recognizes the complexity of individual identities and experiences, while also avoiding the blindness any given researcher or practitioner may have. Finally setting aside the needless hegemony of psychometrics, for example, will allow questions to be asked and progress to be tracked in the client’s own words, using ideas from that person’s own internalization of their cultural history. This will not result in a cacophony, because we are already developing AI tools that can link what a client says in their own words to our knowledge base of processes of change.
#5 Integrating Biological Analysis Without Reductionism
A process-focused approach does not disregard biology. Instead, it seeks a balanced integration of biological, psychological, and socio-cultural levels of analysis. This holistic view respects the complexity of human beings, avoiding the pitfalls of reductionism – as if we are merely expressions of genes, or brains, or any other biological fact. By understanding how these different levels interact and influence each other, we can provide more comprehensive and effective care. But the proper way to understand them is inside life as it is lived, one person, one couple, one family, one community at a time. 30 years ago, this vision would be impossible to mount. Today we have the tools to do it.
#6 Valuing Practice-Based Insights
This shift in focus calls for a greater reliance on practice-based evidence as a source of new information. Traditional research, often confined to the large academic medical center settings that can craft, fund, and conduct large randomized trials, is conducted on and represents only a fraction of the world’s population: the 12% that is Western, Educated, Industrialized, Rich, and Democratic (WEIRD). That sliver of humanity generates 88% of the world’s scientific literature and even more of the world’s scientific citations. Enough is enough. If every voice matters in therapy, then every voice matters in science too.
By valuing insights gained from actual practice, especially in diverse cultural contexts, and by applying measurement and statistical tools that are relevant to practical clinical work, we can develop more relevant and inclusive mental and behavioral health information, and advance our knowledge from the ground up faster and better than the “only randomized trials matter” vision of science. This approach acknowledges the vast diversity of human experiences and the need for mental health solutions that are accessible and relevant to all. And we can mount it at a low cost across the entire world.
The transition to a process-focused world in mental and behavioral health is not just a theoretical idea or a social hope, it’s a practical and necessary evolution that is fully underway right now. By embracing individual processes and contexts, we can revolutionize mental and behavioral health care, making it more inclusive, effective, and empathetic. There will be life after the DSM, and to my eyes it looks much better. We can get there by moving forward together, creating a health system that truly listens to and values every person’s journey.
Liu, H., Xie, Q. W., & Lou, V. W. (2019). Everyday social interactions and intra-individual variability in affect: A systematic review and meta-analysis of ecological momentary assessment studies. Motivation and Emotion, 43, 339-353.