Getting Our Clients What They Really Need

By, Steven C. Hayes, PhD, Stefan Hofmann, PhD, and David Lorscheid

Angela, a forty-year old woman, is struggling after a breakup a few months ago. She frequently ponders where she went wrong, what she could have done better, how she failed the relationship, and she worries she will not have successful relationships going forward. She feels sad and lonely much of the time. A sense of hopelessness and frequent worrying about the future is impacting her work.

As a result, she seeks therapeutic help. She meets with a highly recommended young therapist, who has graduated from a top-notch University, and who diagnoses her as having a major depressive disorder (MDD) at a moderate level. The therapist is very well trained in a popular treatment protocol for MDD that has been extensively evaluated in randomized controlled trials.

After an initial assessment, the therapist focuses on Angela’s dysfunctional thoughts and behaviors – as was described in the manual she favors. Twelve sessions later, Angela’s depressed mood, rumination, and worrying has shown a notable decline, and both were fairly satisfied with the outcome. After her last session she was sent home with instructions to keep practicing the skills she had learned during therapy.

Angela thanked her therapist, but on her way home, she felt a sense of unease. She was clearly less depressed than before, but also realized that she wasn’t close to where she wanted to be emotionally and in life in general. She still felt lonely, and she yearned for, and yet somehow feared, deeper and more meaningful connections with others. “Therapy can’t do everything,” she thought, but in the back of her mind she wondered if maybe she is not the type of person who would ever have committed intimate relationships. She silently vowed to herself that she would not let someone hurt her again as she felt after her recent break-up.

Her therapist would never learn about any of this. She would never learn that in a few months, Angela’s loneliness and sense of disconnection would become an all-encompassing focus, leading her back into depressed mood and feelings of hopelessness. Her next therapist would put her on a relatively high dose of anti-depressants with the rational she clearly has recurrent major depressive disorder that is unresponsive even to evidence-based psychotherapy, but that too would be unknown. Instead, the therapist thought she did a fine job, because she had done what evidence-based therapists should do and the outcomes were seemingly good.

The Shortcomings of Protocols for Syndromes

The case of Angela is entirely fictional, and yet her scenario happens to real-life people almost every day. We cannot be sure that all of Angela’s issues could have been resolved, but we can be sure that some of them received little attention in the first place. Her therapist did not target her loneliness, her relationships, and her feelings of emotional distance. Because these were not thoroughly explored, her therapist would remain unaware of her self-sabotaging, her avoidance of intimacy and vulnerability, and the role it had played in the initial break-up. Instead, relationship and emotional vulnerability issues were addressed only briefly in hopes that as Angela’s major depressive disorder was relieved these would be alleviated as well. Besides, relationship skills were not a notable part of the structured treatment manual, and staying “evidence-based” in the therapist’s mind meant staying fairly close to what was in the manual that has been tested in randomized controlled trials. Hopefully, based on the existing science, this would be enough.

Except, that it wasn’t.

Virtually every clinician has encountered a person like Angela. Our diagnostic system almost demands that evidence-based therapists focus on hypothesized latent diseases instead of real people, in all their complexity. Over the last forty years, our nosology has been built around syndromes, and yet not a single syndrome has turned into a disease with a known etiology, mechanistic course, and response to treatment. Not one. Instead, as every assumption of the latent-disease model is now being openly challenged, many of these assumptions are being falsified. We need another way forward, and Process-Based Therapy (PBT) provides one.

The Process-Based Alternative

PBT is not a new form of therapy. It is a new model of what evidence-based therapy even is, linked to a new conceptual, practical, and empirical approach to the functional analysis of human functioning. Combined with the innovative idiographic measures and statistical methods that are now emerging, PBT casts a bright light toward a very different future for psychotherapy: one that brings together evidence-based processes linked to evidence-based procedures to ameliorate the problems and promote the prosperity of people.

PBT has been gathering steam over the last few years in a series of books and articles but in our just released new book, Learning Process-Based Therapy, we present the PBT model in a way that practitioners can use in a step-by-step way to conceptualize their cases and tailor their interventions.

PBT is built around a few central ideas.

  • People are not normative diagnostic categories; they are unique humans, each with their own story, history, and goals.
  • Human pathology and prosperity can be better understood by focusing on known biopsychosocial processes of change
  • We can systemize the vast literature on processes of change by integrating our various models underneath an extended evolutionary account.
  • We can apply these ideas to unique cases by using longitudinal network analysis
  • We can select treatment elements by which ones are most likely to perturbate self-sustaining pathological networks, while promote positively self-amplifying process of change.

Using the conceptual and practical tools in Learning Process-Based Therapy starts with the view that mental suffering does not mean that people have latent diseases. People become entangled in anxiety, depressed mood and so on because of idiographic networks of biopsychosocial processes based on personal history, underlying biology, sociocultural factors, and the current situation.  In Learning PBT clinicians learn to map out how features of each particular case combine in a web-like network that explains how one thing leads to another in the areas of emotion, cognition, attention, sense of self, motivation, and overt action, given the person’s sociocultural and biophysiological context.

Instead of normative diagnoses, practitioners are taught how to detect known processes of change in these dynamic networks – that is, how to identify and apply the theory-based, dynamic, progressive, contextually bound, modifiable, and multilevel changes or mechanisms that occur in predictable, empirically established sequences and that can be used to produce desirable outcomes.

Once the case is laid out comprehensively in terms of processes of change, the tailored targets of intervention more readily emerge – not as one-size fits all protocols but as tailored interventions that draw from the best of evidence-based therapy.

It is time to move forward. PBT opens the door to a different future in which process-focused scientific knowledge helps our clients get what they really need.

Learning Process-Based Therapy by Dr. Stefan G. Hofmann, Dr. Steven C. Hayes and David N. Lorscheid – is now available for purchase in any major book retailer.

The methods found in Learning Process-Based Therapy are also addressed in Dr. Hofmann’s weekly live online course Process-Based CBT for Anxiety beginning March 2, 2022.

You can also find them in Dr. Hayes’s on-demand course ACT in Practice, open for enrollment year-round.