Process-Focused Therapy

A Guide for Creating Effective Clinical Outcomes

Robert Taibbi

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780815347989
• eBook ISBN: 9781351168380
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Process-Focused Therapy weaves together three key perspectives to help clinicians create a more effective therapeutic session: client problems as faulty process, the goal of therapy as changing such faulty process within the session and the art of shaping the session process for each client. Each practical chapter enables professionals to focus on bridging the gap between the client's language (content) and the clinician's language (process) and on the need to assess and shift this focus quickly within each session to create a new and productive therapeutic experience.

The book starts with the concept of "how you do anything is how you do everything" and details tools that clinicians can use to identify a client's "stuckpoints," (i.e. the faulty process that keeps clients from effectively solving their life problems). The reader is then provided with treatment maps for each of the most commonly presented stuckpoints, and guidance on how to present clients with a preliminary treatment plan. Next, the author explains techniques for building rapport, changing the emotional climate, staying in lockstep, and repairing breaks in the process and shows, through transcribed sessions, how to craft sessions to maximize their emotional and therapeutic impact. Finally, clinicians will learn how to apply these concepts and techniques to their established clinical model.

With rich vignettes included throughout and end-of-chapter questions to invite the reader to reflect on their own practice and consolidate their knowledge of therapeutic processes, Process-Focused Therapy will be a valuable guide for both beginning and experienced therapists.

Chapter 1

Exploring Process

Sara sent her husband a text a few hours ago and now she is livid. He is always blowing me off, she says to herself, he’s always in his own world, he’s inconsiderate. She feels like she is ready to explode and fires off another nasty text.

It’s Tom’s first week on the job and he’s feeling overwhelmed. He’s banging on his supervisor’s door every five minutes with questions about forms, about help with a client, about whatever pops into his head.

If you were to see Sara or Tom in your therapy office, you probably wouldn’t be surprised to discover that Sara freely admits that she has a temper—that her husband’s lack of quick response, or anyone’s lack of response for that matter, is a pet peeve for her. And like many who struggle with anger, she blames others for being the source of, what seems to her, her justified fury. Similarly, you likely would find that Tom’s anxiety over his new job is only his anxiety’s latest focus. This week he is barraging his supervisor with questions, but next week it could be his worry that his girlfriend seems upset with him and he doesn’t know why.

How vs. What

How you do anything is how you do everything. This is a concept that originated in Buddhist thought, but one we in the West and as clinicians can easily resonate with: What we are seeing and hearing in Sara and Tom are the ways they react when they feel neglected or overwhelmed. The Buddhists say, and we would likely agree, that the way Sara and Tom manage the husband, the job, likely fans out across the spectrum of their lives.

To talk about how is to talk about process—the unfolding, the doing, the reacting, the motion of life as individuals go about living: How Tom reacts to stress, how couples talk, how Sara problem-solves with her husband, how a child approaches a new challenge or a stranger; how as opposed to what. What is about content, facts, the information, the particulars that make up what we generally define as a problem; what Sara said in her text, what question Tom asks his supervisor, what Sara’s husband says later or doesn’t say, what Tom’s supervisor tells him to do.

It is content that most often fills our minds—sorting and sifting through lists, the replaying of conversations, the images of what happened or might happen. Content is what fills our therapy offices in those opening sessions with clients—Sara’s story about her text and her husband’s lack of consideration; Tom’s worry about his performance and probationary evaluation. They each lay out their facts, they make their case, they stack up evidence and details to help you understand what it is they are struggling with. They look to you to sift through it all so you can tell Sara that she is or is not justified in getting angry, to help Tom better wrangle all that he feels he needs to master so that he can be successful in his job. Sara’s anger, Tom’s anxiety will subside, they each believe, if they can just get the story, the facts, the content—the what—right in some way.

What is difficult for them to see, because of the tunnel-vision created by their emotions, is the “how they do everything,” their process. Once Sara begins to take you down that road about the story of her husband, it is difficult for her to hear her own blaming, realize that she can choose to respond differently or consider the notion that a different response on her part might create a different one for her husband and change their dysfunctional pattern. It is difficult for her see that her reaction to her pet peeves are hers to fix; instead, her only relief in her mind is to somehow get others to do what she wants.

Similarly, when the content of Tom’s worries is flooding him—the forms he doesn’t understand, the upset of his girlfriend that he can’t mentally deconstruct—it is difficult for Tom to see that his problem in the moment is not the work form or his girlfriend, but his anxiety and the way it is controlling his brain. While his anxious brain is telling him he just needs more information, you realize that what he needs most is to learn to recognize when his anxiety is taking over and then have ways to calm himself. He needs to recognize and manage his own process.

Life and Therapy as Process

This book is an exploration of process as seen through three interconnecting lenses. The first is what we have been already describing—problems as content in motion; process as the movement and management of our lives, the ways we cope or do not cope, the patterns of our actions and reactions, the broad “how we do everything”—all in contrast to content—the facts, the stories that we create that fill our thoughts, ever-changing and composing so much of our everyday reality.

To talk about process is, of course, not new; it is part and parcel of our clinical history, with clinicians always juggling between the content and process within any given session. What is different about the process-focused clinical model that we will look at is one of emphasis—namely, making the faulty process that clients don’t see or don’t know how to change as the keystone of treatment itself, rather than the content or even their views of history that they believe they need to manipulate. By thinking this way, by uncovering what clients can’t—their unique “stuckpoints,” which keep them from successfully running their lives—rather than getting caught up in the content of clients’ stories, our task, and theirs, becomes easier, shorter and largely done. Once they, and we, understand that this is their Achilles’ heel—the “it” that gets in the way of their solving their problems more effectively—and get their commitment to change it, the only remaining challenge is determining what steps they need to take and what support they need to begin to change their process. Once this is underway, they are on the road to success: In spite of whatever content composes their current problems, they now have the skills, tools and attitude to successfully manage them.

While this can sound relatively simple and straightforward, this diligent focus on process is often a challenge if you are working from a more content-focused approach, and especially if you are a beginning or less-experienced clinician. Why? Because it is easy for you to get caught up in content the same way clients do. Like them, you may easily feel overwhelmed by the ten problems there are to fix—children, bosses, money, sex. A parallel process is often generated where just as clients come to therapy with a host of problems “out there” that need to be somehow fixed, now you may come to your supervisor with the same list of problems. Just as clients are looking to you to help them fix all ten of the problems that they have laid on the table, you look to your supervisor to help you do the same. What is being missed is seeing that the one or two issues that thread through all the presenting problems—the clients’ stuckpoints, their faulty processes—are what are driving the problems that they struggle to solve and what therapy really needs to address.

Which brings us to our second perspective on process: Translating clients’ faulty process in their larger lives into the therapy itself. We go back to what we just mentioned: Helping clients realize that the primary focus of treatment is not about drilling deeper into their content—the “what” out there—but the changing the “how,” their process and approach to them. But this too is a parallel process. Just as clients can only relieve the weight of their problems by realizing what is the best that they can do—namely, changing their approach to the content rather than the content itself—you can only relieve the pressure you may feel to help fix all the content in your client’s world by realizing that the only real power you have as a clinician is when you are talking to clients in the room. You have no control over what happens next once they leave.

Which brings us to the second step in this translation: Your being acutely aware of the session process as it unfolds and effectively managing it and ultimately shaping it; the heart of therapy lies within the subtleties of this micro-process. Again, this is difficult to do if you get caught up in clients’ stories, when you falsely believe that when you are feeling stuck you too need to stir up more content, when you fall into a reactive rather than proactive stance.

Instead, your starting point is seeing the shaping of the session process as the medium of change, with you as the creator. The session process is yours to manage and shape, and you do this by making sure that you and the clients are staying in lockstep throughout, that interpretations do not miss their mark, that you notice and address ambivalent responses or when the core problem is being replicated in the room, that transferences don’t undermine the relationship and dilute your message, that clients do not leave feeling the same way they felt when they walked in. Effective treatment is built upon effective sessions, and effective sessions are built upon effective session process, goals and tasks, which you alone are responsible for.

This brings us to our third perspective: Having the tools and techniques to proactively shape the process as it unfolds. This is where diagnosis and overall treatment planning get translated into specific action steps. Here, we talk about concepts and tools of assessment to quickly uncover faulty process and stuckpoints, about knowing what you need to not do in order to avoid problem replication, about having treatment maps at the ready so that you can hit the ground running and create with the clients a sense of energy and direction.

But the additional challenge comes in deciding how to shape this process for each particular client and overriding the easy tendency to adopt a one-size-fits-all approach to clients or problems, as well as uniform one-size-fits-all presentation and use of yourself. Here, we think about therapy as theater, about your use of voice, about the notion of the ideal parent, about creating corrective emotional experiences that give clients an experiential taste of what change really feels like. It is about being conscious and deliberate, and again tracking closely to make sure you and the client are always in lockstep together.

Overview of the Book

The goals of this book are several. One is to obviously increase your own awareness of the role of process in the life of the client, of faulty process as the source of many presenting problems and using this as a foundation for treatment. Another is to show you how to bring this awareness into the process of therapy itself and how to shape session process so its impact can ripple out into the client’s world.

A third goal to help you utilize the session process more effectively and efficiently. By providing you with user-friendly concepts, tools, techniques and treatment maps, the aim is to help you feel less overwhelmed by what happens in the room, and instead feel empowered and able to hit the ground running. Rather than being a scholarly, theory-rich treatise, or one that focuses on specific problems—trauma, psychosis, eating disorder, etc.—think of this book as a guidebook of sorts, both practical and pragmatic for doing everyday process-focused clinical work.

Finally, like many of my other books, this one too hopes to help you better define your own unique approach and style of therapy, because I believe the best clinical practice is one that fully utilizes your own orientation, skills and individual strengths. While we will be using a largely cognitive-behavioral framework for looking at clients and their problems, many of the tools we will be discussing are ones that can be applied to whatever clinical model you choose as a foundation for your practice. As we move along, think about how your approach may differ from what is being described. You’ll find questions and exercises at the ends of the chapters to help you apply the techniques and tools, clarify your own style and assumptions and experiment with effectively utilizing your own personality.

The format of the book is one of moving from the outside in, starting from the client’s larger world and bringing it into the world of therapy, where client problems and personalities get translated into the language and process of therapy. In the next chapter, we will begin this exploration by looking more carefully at that outer world, and specifically the notion of life problems arising from faulty process. To help you quickly assess the client’s and your own clinical goals, we’ll discuss concepts that you can use to define client stuckpoints. We’ll both describe the stuckpoints that are most often presented in outpatient therapy for both individual clients, as well as couples and families. In Chapter 3, we will describe treatment maps for each of the stuckpoints, including assessment questions and initial goals. We’ll conclude that chapter by looking at ways of presenting this information and presenting to clients a preliminary treatment plan.

In Chapter 4, we’ll move into session process and utilizing the concept of pacing and leading to talk about general aspects of running a session. Here, we’ll discuss techniques for rapport building, staying in lockstep, repairing breaks in the process and expanding the client’s world by deliberately creating a new process experience. In Chapter 5, we’ll look at more advanced techniques for crafting the process—therapy as performance—and show how these can be applied to each of the stuckpoints.

In Chapters 6 and 7, we will bring all this together and look at transcribed sessions—one with an individual, another with a client—with commentary along the way. By doing this detailed analysis, you can hopefully see the unfolding of the thinking process, decision options and the way breaks are repaired and positive experiences created.

Finally, in the last chapter, we will talk about applying some of these concepts and techniques to your own established clinical model in order to supplement what you already are doing or to begin to experiment with a new approach.

Let’s begin our journey.

Reflection Questions

At the end of each chapter, you will find questions to stimulate your thinking and exercises to try to increase your awareness and skills. Ideally, work through them all, or find and focus on those that seem to resonate with you most.

1.Define your own clinical orientation or the one that you are most drawn toward. What is it about this approach that most attracts you? How do you see it fitting into your overall values, personality, approach to life?

2.The clinical world divides therapy into content and process. How do you view this seeming split? What role do you place on each of these concepts in your own life?

3.How do you think about the source of problems in one’s life? What for you is the purpose and focus of therapy?

Part I

The Outer World

Problems as Dysfunctional Process

Chapter 2

The Landscape of Faulty Process

In a 1921 letter to Countess M., the poet Rainer Maria Rilke wrote, “Everyone, in the last analysis, experiences only one conflict in life which only disguises itself differently all the time…” (Bannard, 2012). In our process-focused approach, we are on the same path as Rilke. What he calls a conflict that continually runs through an individual’s life we are calling stuckpoints—the faulty process, the “what can’t you do.” But the notion is the same—namely, that though the “disguises” or content may vary, there is...

Table of contents

• Cover
• Half Title
• Endorsement
• Title Page
• Copyright Page
• Contents
• Chapter 1 Exploring Process
• Part I The Outer World: Problems as Dysfunctional Process
• Part II The Inner World of Clinical Process
• Index