Moving Away From the DSM and Toward Evolutionary Science: Process-Based CBT

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An Interview with Stefan Hofmann, PhD & Steven C. Hayes, PhD

This interview is regarding your recent textbook Process-Based CBT. In a recent Psychology Today blog article, Hayes writes that ACT (acceptance and commitment therapy) was seen at one time as a “rebel threat to CBT.” Since then, you have both come together from the cognitive behavioral therapy and contextual behavioral science worlds–worlds that were at one time viewed as separated or oppositional—to collaborate on this book as a result of a task force within the Association for Behavioral and Cognitive Therapies.

What, if anything, do you both still disagree on, having to do with the two branches of psychology that you represent (Hayes: CBS/ACT, Hofmann: CBT)? How are the arguments/discussions between these two branches evolving lately?

CBS/ACT is rooted in Skinnerian and post-Skinnerian views about the role of cognitions and language, and pragmatic functional contextual assumptions that focus on context. CBT has been influenced and shaped by the cognitive revolution, emphasizing the importance of cognitions as the primary mediators for treatment change. These reflect fundamental differences in philosophical assumptions. However, our firm commitment to the scientific approach, testable theories, and values to improve the human condition unites us. This, and our mutual respect, love, and friendship overrides any apparent differences. The result is a quest to re-examine our current diagnostic system and the way we treat people so that we can make better progress. We believe that we not only identified the problems, but also have the beginning of the solution: Linking the processes underlying treatment change to the strategies and the individual person.

Could you give an elevator ride’s length history of why the Inter-Organizational Task Force on Cognitive and Behavioral Psychology Doctoral Education was formed, and how your book Process-Based CBT is an answer to its recommendations?

Bob Klepac (former president of ABCT) organized an impressive and very important Task Force to provide doctoral programs of clinical psychology with general guidelines for developing their curriculum for clinical training. The Task Force was very thorough and all-inclusive, not limiting itself to any theoretical orientations. As a result, the report included a thoughtful discussion of the various and sometimes contradictory theoretical orientations and then focused on specific strategies linked to mechanisms that students should know in order to become effective and competent clinicians. Obviously, this is only the initial stage. But what’s important was that the Task Force naturally walked away from the “treatment-protocol-for-DSM-diagnosis” approach and tried to sketch out mechanisms and strategies to effectively target the individual patient, rather than a DSM category. As a result, it brought us back to our behavioral roots of idiographic functional analysis in order to understand and answer Gordon Paul’s famous question, which he formulated back in 1969.

Is now the perfect time for process-based CBT to emerge? Why or why not?

The field is at a tipping point. Individuals are squeezed into narrowly defined DSM categories. As a result, the client becomes the summation of DSM codes and each code is associated with one or more specific treatment protocols. It’s not only a matter of feasibility, but also one of validity. The notion that a person “has a disorder” is not merely an oversimplification, but this “latent disease model” is quite likely simply wrong. It is time to declare the biomedicalization of human suffering to be the failure it is. But that is not enough. We need an alternative. Process-based CBT is true to our roots, and changes in the field make it possible to us to mount the scientific and clinical agenda it lays out.

Do most mental health professionals really live in a “post-DSM era”? For those who don’t—or can’t—for insurance/billing or other reasons, how can process-based CBT serve them?

Many practitioners have never really lived in the DSM area—they have just allayed the DSM game. That may continue for some time but the point is to create a viable alternative that will help empower clinical work in the meantime. The DSM was never more than a list of arbitrary codes to primarily facilitate reimbursements. It is hard to find any serious clinical scientists who believed that the various editions of the DSM got us any closer to the understanding of the causes and treatments of psychiatric disorders. Effective practitioners naturally try to understand the processes underlying the treatments changes. Depending on the theoretical orientations, clinicians naturally differ on what they believe the primary process might be. This should become an empirical question, not a matter of opinion.

Few clinicians would argue that the individual is unimportant and that symptoms and syndromes should be the main target, regardless of the background of the person, the cultural and social context, and the person’s relationships. Such a clinician would not be very effective. Yet, the DSM gives us exactly this framework to understand and heal human suffering. Without money from National Institutes of Health (NIH), little American Psychological Association (APA), and other powerful agencies and groups that have been supporting this, the DSM probably could not have survived for as long as it did.  What Process-based CBT offers is a coherent way to work with clients and to think about intervention that takes advantage of the best available evidence ad we move toward a new form of functional analysis.

In the book, you state that the end of named therapies (e.g., cognitive behavioral therapy) is likely, because they’re becoming too narrow. Why? In what ways are named therapies too narrow? What do you think will replace beyond therapies? What does this mean for day-to-day work with clients?

CBT is undoubtedly one of the great success stories in psychiatry. However, over the years CBT became too closely aligned to the DSM and became defined by sets of techniques instead of processes of change. As a result, a cottage industry of trademarked or certified trainings on technolgies emerged. That restricted research, clinical creativity, and the ability to fit knowledge to the individual. Once named technologically focused trainings are in place, there is little incentive to study them empirically or even change them. This artificial specialization was financially lucrative for the treatment developers and trainers, but it led to the narrowing of the field and undermined research progress. We need to move away from it.

We need to study and understand the processes, based on theories, that drive treatment change in a given individual, develop strategies to target these processes, develop algorithms to predict who is likely to benefit from it, and then train clinicians in these strategies. At the same time, we need to keep the system open for testing and falsification.

There is still room for named models and therapeutic methods linked to them, provided the process evidence for them is good and their focus is broad enough to be worth clinical attention. Steve thinks ACT can make it through that filter for example, but more as a way of changing psychological flexibility than as a list of techniques.

Could Process-based CBT apply to other fields or professions beyond psychology?

Process-based CBT applies to any field focused on behavior change. Every time we want to understand change, we need to study processes and procedures. This goes well beyond psychology.

Does the timing of the emergence of Process-based CBT intersect with the booming of behavior analysis? How?

It is in line with a general change in zeitgeist: Away from simplistic, univariate, and unidirectional relationships toward understanding the complexity of a phenomenon. It might require big data, even for a single person. As an applied discipline behavior analysis has been growing, and it has always had a process focus—but more narrowly focused on direct acting contingencies. That does now appear to be broading which may open up applied behavioral analysis to many additional processes.

What are the next steps/progressions you see for Process-based CBT?

Our hope is that the field will embrace this notion. This is a paradigm shift. It will not only force us to step away from treatment manuals and the DSM, but also forces us to re-examine ideas that might not be fully consistent, and that might even be contradictory, to our own theoretical views. For this, we need to build a model of models that can incorporate any such change processes. Steve and I (Stefan) believe that evolutionary science can offer such a model of models. We have been working on this notion and will present our ideas when they are ready.