What are Problem Solving Brief Therapy Transdiagnostic Techniques
The diagnostic model, which focuses on identifying specific diagnoses and targeting symptoms, has guided psychologists, shaped therapeutic protocols, and influenced how patients understand their mental health struggles. However, despite its widespread adoption, the era of diagnosis-driven therapy is undergoing a seismic shift. Increasingly, recent research is questioning the efficacy, limitations, and ethics of this traditional framework.
This shift is prompting therapists to focus on transdiagnostic approaches, such as the one proposed by the Problem-Solving Brief Therapy Model over half a century ago.
Too often, when collaborating with and supervising teams rooted in different theoretical approaches, therapists express distrust and reluctance to apply a model that does not begin with a few exploratory sessions dedicated to obtaining a diagnosis. Moreover, without the crucial presence of a diagnostic label, they are unsure which predefined protocol to apply in each case or how to track their client’s progress. Years of specialization may ultimately fail therapists , even worse, lead to the prescription of medical treatments by a psychiatrist and ultimately not serve their patients in the best way possible
The diagnostic approach in psychotherapy is rooted in the biomedical model, where mental health is treated the same as physical health: diagnose the presence or absence of a disorder, assess its severity, and then help to alleviate symptoms.
Diagnoses and protocols provide a comfortable framework for experts, supported by a solid theoretical background. If the client improves, it is attributed to the treatment. If they do not improve or drop out, it is seen as resistance on the client’s part. In such cases, the solution often is to increase the frequency of sessions or switch to another form of medical treatment, such as psychiatric medication.
However, new research indicates that disorders once considered distinct often share genetic, environmental, and neurobiological factors. This overlap challenges the rigid structure of diagnostic categories and signals a shift in how mental health is understood and treated.
What are some KEY concepts that challenge diagnosis driven therapy?
- Non-ergocidity
It is common to confound science-based evidence with average-based evidence. However, most practitioners know that individual trajectories differ significantly from group-based averages. The concept of non-ergodicity suggests that the experiences of individuals do not always reflect the statistical or aggregate properties of the larger group over time. Individuals with the same diagnosis, like Major Depressive Disorder, may experience very different symptom profiles, challenging the assumption that disorders are stable or uniform over time. - Rampant Comorbidity and Poor Discrimination
Mental health symptoms often overlap across different diagnoses, making the boundaries between disorders blurry. High rates of comorbidity (multiple diagnoses in one person) and symptom overlap imply that mental health conditions may lie on a continuum rather than existing as separate categories. The P-factor, a unified measure of brain health, may better account for comorbidity and dimensionality of symptoms. - Biopsychosocial Multicausality
Mental health issues result from complex interactions between biological, psychological, and social factors. Mental health diagnoses do not always reflect distinct, underlying realities. As such, focusing on finding a singular cause of symptoms may not lead to better interventions. - Dimensional Symptom Space
Many mental health symptoms do not fit neatly into category boxes. Instead, they exist along continuous dimensions. Diagnoses that impose binary distinctions (e.g., present or absent) fail to capture the complexity of symptoms and contribute to diagnostic instability and interrater reliability issues. Additionally, some symptoms matter more to the client than others, so focusing on what is important to them may increase adherence, motivation and provide better results. - Incomplete Symptom Capture
Diagnostic manuals often miss certain symptoms observed in clinical practice, leading to less accurate diagnoses and treatment plans. There are processes which include cyclic causality that are observable in clinical practice and absent from diagnostic models. - Phenotypic Plasticity
Mental health conditions may shift over time, with individuals shifting between diagnoses or showing different symptom patterns within the same diagnosis over time. This variability is not well-captured by diagnostic systems, which often use cross-sectional snapshots of symptoms. It is important to continue to focus on what the client brings and is interested in changing. - Increased medicalization of mental health
There is a growing trend of framing mental health conditions primarily as medical disorders. While medical treatments can provide relief for many individuals, this approach may also oversimplify complex human experiences, pathologize normal emotional responses, and reduce the importance of non-medical forms of support. - Diagnostics may jeopardize time and efficacy
If we lose too much time with diagnosis we may lose adherence to treatment and efficacy. There is a predictive value of early session outcomes. A study by Lambert and Ogles (2004) indicated that early symptom relief, particularly within the first 4 to 5 sessions, was a strong predictor of long-term therapeutic success, even in the absence of a fully developed diagnosis. Client engagement during the first few sessions is another early predictor of success. Clients who are more engaged, open, and committed to the therapeutic process are more likely to experience positive outcomes. A study by Wampold et al. (1997) showed that early client expectations of therapy had a stronger effect on outcomes than the therapist’s specific treatment methods.
Another study by Duncan et al. (2004) found that clients who received feedback in the first few sessions, and where therapists adjusted treatment accordingly, showed greater improvement compared to those who did not receive this feedback.
How has Problem Solving Brief Therapy functioned effectively as a transdiagnostic model of intervention?
Symptoms are subjective experiences while clinical labels are theoretically objective and arbitrary. Our model opens the diagnostic boxes to accept the symptoms that the client – and not the therapist- reports as ‘the problem’, would contribute to improve treatment efficacy by establishing goal consensus and increasing therapeutic alliance.
How does Problem Solving Brief Therapy make the leap to tailor made?
As our director, Karin Schlanger, often says, ‘each case is its own best explanation’. Non-ergodicity challenges the idea that a “one-size-fits-all” treatment approach can be applied to individuals with a given diagnosis. Therefore, our way to create flexible and tailored interventions for each case respects the transdiagnostic assumptions. We do this through multiple skills like observation and communicating about the process, following the principles of change and implementing the relational strategies of promoting motivation, respectful regard and utilizing the clients view of their world and problem.
THERAPISTS MORE THAN EXPERTS ARE SOLUTION CO-CREATORS
The therapeutic relationship itself is a dynamic and evolving process that cannot be standardized or universally replicated. The success of therapy is contingent on the specific relational dynamics between the therapist -the technician- and the client -the expert about the problem to be solved- . Thus, therapy is a co-created journey rather than a fixed protocol-driven intervention.
CONTEXT IS KING
We design interventions that take into account the client’s expectations, preferences and limitations. We take into account their context, where minimal changes are encouraged to take place. and start with small experiments in their already existing environments to increase adhesion with the least of efforts.
BE BRIEF. FOCUS!
Investing time to get a diagnosis may negatively influence therapeutic success since what happens during the first 3 to 5 sessions predicts therapeutic success. Starting to intervene from the first session (or even before) maximizes therapeutic outcomes and makes clients be more engaged, open, and committed.
In conclusion, the future of mental health care depends on shifting away from rigid adherence to DSM categories and embracing a more individualized, flexible approach to treatment. By focusing on personalized care that takes into account each person’s unique circumstances, we can enhance the effectiveness of therapeutic interventions and increase the likelihood of long-term success.
Problem Solving Brief Therapy (PSBT) presents a promising alternative, offering a lasting, efficient, and ethical method that aligns with the principles of transdiagnostic therapy. As a meta-theoretical framework, PSBT adapts to the needs of diverse individuals, making it a versatile tool in the pursuit of meaningful mental health care.
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