A Process-Based Approach to CBT (eBook)

|5|Foreword

Why a Process-Based Approach Is the Next Logical Step in CBT

A process-based vision is not new to cognitive behavioral therapy (CBT), but our field has been through so many years of narrowing, caused in part by our own success, that today it can feel as though it is entering the field orthogonally rather than as a historical foundation. An evidence-based approach to psychological intervention began with the task of applying well established principles to the problems of an individual, but it was not long before the central task came to be to diagnose a problem based on signs and symptoms, to categorize these under a specific mental disorder label, and to apply a manualized set of interventions aimed at reducing those signs and symptoms. CBT was spectacularly successful in that task, and that approach helped CBT prosper world-wide. But a sense of stagnation has now arrived, due in part to the galling fact that our effect sizes are not increasing (Hayes, Hofmann, & Ciarrochi, 2023). We need a new way forward.

A process-based approach returns our field to the difficult but exciting task of modeling the complex interplay of affect, cognition, attention, sense of self, motivation, and overt behavior, along with processes in the sociocultural and biophysiological domains, in order to understand why problems arise and persist and how to resolve client problems and promote greater prosperity. Instead of the fruitless pursuit of latent mental diseases, our field is moving towards a new vision in which it is the task of the CBT clinician, and all evidence-based clinicians, to answer this 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?” (Hofmann & Hayes, 2019, p. 38).

The book you have in your hands takes a sober look at the situation and draws on the now large body of basic and applied knowledge regarding process of change, from basic science to third-wave methods in CBT, and applies it to the radically “transdiagnostic” task of answering the key “what,” “why,” and “how” questions that have always been part of our professional and scientific journey. Why did this problem develop in the first place? What are the goals of the client and what is needed to initiate change? How will change become self-amplifying or be maintained?

This well-written book is not a cookbook of methods, nor it is theoretical tome. It is a practical process-based road map that describes in a step-by-step fashion how to take a process-based approach to CBT, and how to so deeply understand the dynamic of your clients’ psychological problems that they can be changed in a systematic fashion that is both strategically sensible and empirically sound.

While traditional evidence-based therapy often employs a nomothetic approach, aiming to generalize from a sample population to individual cases, a process-based approach is idionomic in nature, focusing on the unique characteristics of individual clients but then generalizing them as warranted to nomothetic principles, provided always that the clarity of the individual is thereby increased or at least not compromised. A client is never |6|treated as an “error term” in this approach, nor in this volume. Each unique person is still unique, and a process-based approach sets as its goal that the person will be seen even more clearly and heard even more thoroughly by the analytic steps taken.

That is not mere rhetoric. You will sense as you use the methods this book contains that they bring you as a provider closer to the idiosyncratic details that often get overlooked when we focus on latent disease entities. You will better understand your clients and the options you have to create progress will be more illuminated.

A process-based approach moves practitioners away from a static, linear, pauci-variate model of psychopathology to one that is dynamic and network-based. A process-based approach accommodates complex models of causality, such as feedback loops and dynamic systems, which capture the nonlinear and multicausal nature of psychological phenomena. This approach enhances our understanding of why treatment works when it does and sets the stage for more targeted, kernelized, individualized therapeutic strategies.

This process-based approach recognizes and enriches the strengths of CBT. Svitak and Hofmann are not saying “let’s discard our CBT methods.” Instead, they are saying “let’s understand why our interventions work, for whom, and under what circumstances.”

Pursuing a process-based approach is akin to training to be a master chef who knows not just the recipe but also the intricate interactions between ingredients – the subtleties that transform a dish from good to great. It seeks not to replace CBT but to evolve it, to move from a focus on what we should do in therapy, to how and why we should do it, in a way that is attuned to the individual complexities of each client. It is an invitation to be more nuanced, more flexible, and, ultimately, more effective in our practice.

This well-written book lays out the problems of traditional diagnosis and its excessive focus on a nomothetic search for latent diseases, and instead proposes a more idiographic, complex dynamic network approach to psychological difficulties. This shift is not an abstract academic matter – it is an urgent call to action and attention by researcher and practitioners alike. The subpar remission rates in intention-to-treat samples highlight a daunting truth: We are only partially effective in our therapeutic endeavors.

As network thinking is initially explored by the authors it becomes evident that it matters how we conceptualize and analyze client problems, and their predisposing, contextual, sustaining, and protective or positive factors. The authors detail a system of understanding and tracking the major known processes of change, and how they might be impacted by the core processes of psychotherapy.

English readers might be surprised to find that a forward looking and very well-known German psychotherapist, Klaus Grawe (1995), long ago laid out a vision of a scientifically based psychotherapy that focused on relevant processes of change rather than on diagnoses and therapeutic procedures. Details of his theory have not been well validated but his work makes it easier to understand how a process-oriented approach can indeed provide an umbrella for the systematic application of evidence-based methods that modify the processes establish and maintain a pathological network. It also explains why the German psychological community has been particularly welcoming to a process-based approach and is assuming a leadership role worldwide in this area.

A strength of this volume is the detailed way that these core ideas are linked to phases of process-based psychotherapy, from recognizing processes and exploring their determinates, to creating a process-oriented functional analysis and repeatedly assessing client progress. This is a practical volume that has already gone through the hard test of application in systems of care. When the dynamics of a case are clear, a rational kernel-based |7|intervention plan can be uniquely constructed and targeted toward client needs, and an iterative virtuous cycle of monitored steps towards goal attainment can ensue.

In the latter parts of the book, the focus on practical application, assessment tools, and real-life examples offers a seamless bridge from theory to practice. Therapists are not just offered abstract concepts but actionable steps, forms, measures, and strategies to bring the process-based approach to life within the therapy room and system of care.

We have to acknowledge that while meta-analyses already show that taking a more personalized approach produces small but significant therapeutic gains (Nye et al., 2023), a lot remains to be done empirically. But this approach is more a model of how to apply existing knowledge than a radically new set of proposals disconnected from our existing research base and therapy traditions. You can still be you in a process-based approach and the methods that matter can still be used. What is different is your ability to do so is guided by process-based evidence that has been there all along, unseen because of our excessive latent...