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Review of "Process-Based CBT"

By Steven C Hayes and Stefan G Hofmann
Context Press, 2018
Review by Roy Sugarman, Ph.D. on Jul 17th 2018
Process-Based CBT

Astute readers will note that Hayes and others here are also proponent experts in ACT, a 3rd generation CBT, so the level of expertise to start is quite high.

The gains to be made on this widely used way of helping people overcome mental illness include going beyond what is currently written, and opening new perspectives vial the application of science and philosophy both. In this way, as with ACT, the idea is to increase our focus on core therapeutic processes, in order to influence training and practice in the future by re-examining the core and thus translate this into improvements. Evidence-based is synonymous with science, and so the book targets this synergy. CBT is therefore not approached as a single entity, with cognitive and behavioral juxtaposed, but rather, again, as with ACT, a subset of third-generation CBT (plural). The criticisms from evidence based psychiatry would have included, across the years, the complaint of loss of contact with the personalized nature of human suffering, and again this is dealt with here, with redress to concerns that emotions, motivational drives, interpersonal skill level and the like are not dealt with in standardized, manual-driven CBT.

The editors as authors look to the history, as I note above, of CBT as an evidence-based approach to mental health, in order to fend off criticisms for decades that psychology was soft on science and high in art-form. Criticizing the Biomedical model was just the beginning, and defining the targets of psychotherapy and such interventions depending on focusing on a clear epistemology, much in the way early neuropsychologists defined their targets, namely brain-based behavior vs. some esoteric ghost in the machine. CBT thus came to focus on maintaining factors rather than the initiating factors, and hence spent little time worrying about how these symptoms came to be, but rather on what kept them going long enough to cause dysfunction. This was opposed to the ACT view of the matrix that creates and maintains psychological inflexibility, and pays less attention to focus on maintaining thought processes. ACT is less interested in what mental illness category is present, given so many illnesses are comorbid with others. Movement was thus to the core dimensions in psychopathology, and thus core processes in CBT, which leads to the ACT idea of a network of interrelated elements that result in the disorders that we recognized diagnostically. A thousand people taking one medication does not illuminate on the 1000 pathways of interrelated elements of each complex presentation. Identifying these core processes is thought to be the wave that will take us into the science of the future approaches to mental health treatments: hence process-based CBT.

Sean Hughes looks at the philosophy of science and how it applies to a clinical approach, and Kelly Koerner on science in practice, namely on the challenges of using evidence-based practice as I noted above, in clinical decision-making, where clinical judgement relies on art rather than evidence.  In her way, one links therapeutic targets to robust change processes. Andersson changes it up by introducing the idea of how information technology has played a role in changing methods of practice, the internet being what it is, and guided self-help becoming a feature of standard therapy. I note for instance that the free to air 'Be A Looper' app has both been nominated for awards and gone viral, given it augments contact between troubled patients and trusted others, as well as modelling emotional vulnerability as a desirable trait to be shared with others (Be A Looper: Social Health Innovations Inc, 2017).

Kenneth Pope is then chosen to speak to ethical competencies in behavioral and cognitive therapies, vital to the idea of targeting processes that lead to illness, as opposed to just the maintaining factors, in the training of practitioners.  Pope recalls the time we all embarked on anger management training which included beating various equipment with our fists or other bits of equipment, with a contrary evidence base later to emerge as to what we were hoping would be the outcome. There was a solid grounding in theory: the outcome didn't match.  17 helpful steps are set out at the end for confronting ethically-tricky decisions.

As you will have gathered, the core processes that lead to discomfort are the key here, and so Dixon and Rehfeldt take over now to lead us in to these.  They cover all of the ones we would expect, e.g. operant conditioning and others, which lead to precise principles from which we can derive treatments. Jan de Houwer and the Barnes-Holmes' pair now query the nature of cognition, taking a functional-cognitive perspective, information-processing being the typical definition, but in functional terms, this switches to conceptualizations of behavior. These terms can be reconciled in a functional-cognitive argument, which these authors set out to do. Papa and Epstein look at emotions and the critical arena of regulation of emotions, an executive skill, and as with the previous authors, the clinical implications of these processes require illumination.

Siegle and Coan then cross into the neuropsychological processes I mentioned in passing above, namely bridging the processes into defining the neurology that underlies cognition and behavior.  Insights of one, especially the medical science, allows an ecosystem to be built with psychologists. Looking at it from a brain network perspective makes sense, given we are interested in processes and related (dys)function, following on what mirrors an integrated approach, namely default mode, social and reward processes, salience and executive, key words one can look up to find out where the action is in relevant neuroscience.  Particularly interesting here from an ACT, 'defusion' perspective are the distancing studies (66 of them) where only one focused on emotional regulation, and none that reference defusion. Motivation is another fascinating one, with neural data suggesting that motivational strategies capitalize on the brain's ability to conceive of otherwise difficult actions as being rewarding, the way the brain deals with ambivalence.

Hayes comes back in, together with Monestès and Wilson to deal with evolutionary principles, the six key concepts of variation, selection, retention, context, multilevel selection, and multidimensional selection.  It gets very slim in how we use these in clinical work though. Higgins, Kurti and Keith speak of contingency management, going back to Dixon and Rehfeldt above, namely the systematic delivery of reinforcement contingent on achieving predetermined clinical goals, and the opposite if these goals are not met. Their case study is of limiting or eliminating smoking during pregnancy.  McIlvane focusses on Stimulus Control and how this works in the clinical and educational environment.  Miltenberger, Miller, Zerger and Zovotny take on the process of Shaping, again well known to all of us, and as with the previous authors, focus on implementation, namely identifying the target behavior, determine if shaping is the best approach, identifying the first of the proximal behaviors to be reinforced, determining the rest, the reinforcer for each, the differential reinforcer for each, and the pace at which you might move through the process of shaping.

Self-management is another interesting application, encouraging the desirable and discouraging the undesirable as opposed to conditions that accomplish the opposite. The usual aspects of assessing behavioral change are reiterated here, and the changing of emotional behaviors. Arousal reduction refers to McKay's contribution to the book, targeting the sympathetic nervous system and not the results of cognition. These interventions include breathing techniques, progressive muscle relaxation, passive relaxation, applied relaxation training, mindfulness techniques, visualization and autogenics, all of which are covered here in some detail. There is no specific mention of HRV training to target both sympathetic and parasympathetic systems, despite the work of various San Diego researchers in the field.

Aldao and Plate take these targets further, in coping and emotional regulation, modifying the intensity and duration of their emotional reactions to the world, in order to respond to daily challenges with less intensity. Reappraisal and acceptance come in immediately here, and in keeping with ACT, the role of context is next, with regulatory drift and multifinality playing roles, largely drawing on however on a more CBT approach, such as Beck's work for instance in the different types of reappraisals possible.

Nezu and colleagues address the most important aspects of contemporary problem solving therapy, a psychosocial intervention that emphasizes adaptive problem-solving attitudes, for instance enhancing sense of self-efficacy, and behaviors.  The idea is that attempts at coping that are ineffective undermine a sense of self-efficacy, and so more effective strategies are introduced and practiced. Building resilience is thus the goal, as much as curing the process that lead to ineffectual problem-solving in the past. Again, there are processes underlying this, such as emotional dysregulation, cognitive overload, and so on. Toolkits for dealing with each are handed over.  Moving on to exposure strategies, to overcome avoidance, Davies and Craske help patients face a fear associated with a stimulus by repeatedly facing the stimulus.

One of my personal favorites follows, Behavioral Activation, in the hands of Martell. BA has been recognized as part of CBT but also as a stand-alone approach, taking into account empathy and warmth, attending to the present moment as in being mindful, and validation (roughly compassion for their experiencing difficulty) and implicit acceptance (of context in this case). Values, reinforcement and activity monitoring come in here as well, and one can see how ACT evolved from much of these considerations, for instance with personal values requiring some extra consideration. An attempt has been made to not neglect aspects of other therapies beyond CBT, such as Interpersonal Therapy, and the focus of Mueser here are the skills associated with this training. Effective communication leads to seamless realization of necessary interpersonal goals since we do not live in isolation, or at least should not. Skillfulness includes interpersonal skills, nonverbal and paralinguistic behaviors are also contingent on not conflicting with the verbal, and effective social interactions also require social cognition to be artful, perhaps drawing on empathy and theory of mind and other formulations. Steps of common skills taught in IPT are given here as well.

Cognitive reappraisal is a pillar of CBT, the duty of Amy Wenzel in this volume, entertaining thoughts without necessarily accepting them, the Aristotelian definition of an educated mind, so critical to our post-truth present. Altering an emotional response to a thought thus becomes a staple of CBT. Of course, identifying the maladaptive thinking at the start is crucial, and then the tools to work on these becomes the next step, such as thought recording, coping cards, and the use of technology beyond that. Arntz works on modifying core beliefs, a reference to Piaget-Beck's schema concepts. Schemas have the effect of confirmatory biases, and are often hard to shake.  Understanding the origins, and discovering and formulating core beliefs is necessary if the cascade of negative cognitions, driven by the core schema, is to be avoided in the face of an unpleasant reality. 

Central to CBT now, and emerging from ACT is the concept of defusion, mentioned earlier in the context of distancing, and Blackledge takes this on. This means moving beyond the content or literal meaning of a thought, a metacognitive approach if you will. Less investment in a negatively biased belief system would mean less acceptance of confirmatory events, and challenging the bias, or being relieved of them. Thoughts are not the ultimate arbiter of truth and reality, no matter how compelling, and fusion means taking thought as if it were immutable truth, a proxy for real events, excluding the CBT reliance on alternative 'truths' to use the Kellyanne Conway term. The focus here is on the relationship of the person with their thoughts, not the thought challenge as much as it is in traditional CBT.

Forsyth and Ritzert tackle the cultivation of psychological acceptance, again another aspect that has received more attention in CBT. As a core process, even in religion, it has come to the fore again here and involves change in how one approaches psychological events, involving openness, flexibility and compassion. The skills of this are taught here. Another central issue in ACT is the value of values choices and the clarification of this, and Lundgren and Larsson describe how patients lose contact with what was meaningful (so important in mastery concepts) and provided purpose based on what they used to cherish (think Frankl and Rogers). Four areas of 'values' are cogent: Work-Education, Leisure, Relationships and Personal Growth/health and clarification is important, to deepen a sense of what is cherished as a life value. No discussion of any of the above strays too far from mindfulness, the focus of Ruth Baer in the next chapter. Close too is the concept of motivational enhancement, and this is next from MacKillop and colleagues.

Twenty-eight chapters into this comprehensive look at what is essential in terms of processes and competencies, Comtois and Landes are tasked with crisis management and suicidality, so important as I note above under the heading of technology such as apps and virtually every developed country has focused increasingly on this burgeoning problem in the face of modern challenges. Sadly, there is little evidence as to whether inpatient or outpatient is best, and the jury is out in terms of comparative studies, although there is ample evidence for outpatient treatment being efficacious. Being part of a team is vital as there is no formula that can tell if a particular person is likely to commit suicide in the outpatient setting, and multiple opinions are best considered.

The editors conclude by returning to discuss, crucially, the future directions in CBT and evidence based therapies. These include the decline of named therapies (process), general theories, the rise of testable models in the service of science, the rise of mediation and moderation, as well as new forms of diagnosis and functional analysis, idiographics rather than nomothetic systems approaches, specificity of modifyable elements in processes, the importance of context, and other issues that have emerged across this book.

The confluence of older CBT with the newer generation CBT's such as ACT is clear throughout as well, and the editors have collated all the elements well. As a predicted textbook for the future of training clinicians, I think it just might do the trick. Feedback-based therapies might be a worthwhile inclusion, more of the DBT approaches perhaps including telephone and group support, others such as psychodynamic approaches (?) perhaps might prove valuable where personality is an ongoing issue, and the processes that emerged fixedly from these, but overall, I think the editors got it right.


© 2018 Roy Sugarman


Roy Sugarman PhD, Director: Applied Neuroscience, Performance Innovation Team, Team EXOS, Arizona USA