Vers un protocole de traitement processuel et modulaire des troubles anxio-dépressifs

Recently, the approach of applying a validated treatment protocol as a function of the psychiatric disorder diagnosed has been questioned. Among the limitations highlighted, is the fact that, in most cases, people presenting a mental disorder also suffer from co-morbid mental disorders. In these conditions, it is uncertain how to determine a treatment approach based on protocols that have been validated for uni-morbid cases. Others have also pointed to the great diversity of individual profiles within the same diagnostic category, questioning the relevance of a single treatment for different cases presenting the same diagnosis. Finally, from a logical standpoint, some claim that any treatment should address the cause of the disorder (i.e. etiopathological processes) and not its effect (symptoms determining the diagnosis). To overcome these limitations, a transdiagnostic, processual approach has been proposed. This approach supposes that there are psychological processes common to different diagnoses, and that treatment should target the cause of the disorder (i.e. the underlying psychological processes) and not its consequences (i.e. the symptoms and the diagnoses). In this article, building on the transdiagnostic, processual perspective, we present a new way to conceive psychological treatment of mental disorders: the processual, modular approach. In this approach, case conceptualization is central. It aims at identifying the psychological processes that are responsible for the onset and maintenance of the disorder. Based on this processual case conceptualisation, the intervention targets the specific processes that have been found active in a given individual. More precisely, the intervention consists of the concatenation of modules, each module targeting a specific etiopathological process. Hence, the end-treatment, the concatenation of modules, is individualized according to the specific processes that have been identified as determining the condition of a specific individual. The proximal validation of this approach relies on demonstrating that the processual case conceptualization accurately identifies the psychological processes that maintain the problem and that each module is indeed effective in altering the psychological process it targets. The distal validation would be to demonstrate that this new approach is more effective in reducing symptoms than the traditional “diagnosis-based treatment approach”. We expose a case conceptualization module that aims at identifying the main processes that are active in anxio-depressive disorders in adults. Based on a literature review, we have identified seven classes of processes: experiential avoidance and behavioral deactivation, dysfunctional emotion regulation strategies, meta-cognitive beliefs, helplessness and poor self-efficacy, gaps between actual self and ideal or socially prescribed selves, mental rumination, and intolerance to uncertainty. From the literature, we have selected self-reported questionnaires measuring each of these processes. Special care has been given to choosing questionnaires easy to use in everyday regular clinical practice, and that allow for constructive feedback with the clients. The structure and underlying dimensions, psychometric characteristics, validation in English and in French are presented for each questionnaire. The selected questionnaires are the Multidimensional Emotion Avoidance Questionnaire (MEAQ), the Emotion Regulation Questionnaire (ERQ), the Meta-cognition Questionnaire (MCQ), a specially designed questionnaire assessing self-efficacy in a variety of life situations, a specially designed questionnaire defining the ideal and the socially prescribed selves of the client, as well as the gaps between these selves and the actual self, and the distress it triggers, the Cambridge-Exeter Repetitive Thinking Scale (CERTS), and the Intolerance to Uncertainty Scale (IUS). The resulting clinical instrument for case conceptualization is presented and its limitations are discussed. This article is complemented by a sister article in this volume that presents a clinical case, conceptualized with the present protocol.