Learning Process-Based Therapy: A Skills Training Manual for Targeting the Core Processes of Psychological Change in Clinical Practice

by Stefan G. Hofmann, Steven C. Hayes, David N. Lorscheid

Step-by-step guidance for implementing process-based therapy in practice Evidence-based mental health treatments—including cognitive behavioral therapy (CBT)—have long been defined in terms of scientifically validated protocols focused on syndromes. This is rapidly changing. A process focus is now emerging for evidence-based therapies, as the era of “protocols for syndromes,” passes away. This groundbreaking book offers concrete strategies for adopting a process-based approach in your clinical practice, and provides step-by-step guidance for formulating effective treatment plans. Written by renowned psychologists Steven C. Hayes and Stefan G. Hofmann, this manual will show you how to utilize the core competencies of process-based therapy (PBT) in a way that honors the behavioral, cognitive, and acceptance and mindfulness wings of CBT and builds bridges to other models. In the book, you’ll find a comprehensive road map to the theoretical foundations of PBT, as well as techniques for creating customized treatments that address the unique needs of each client—leading to better therapeutic outcomes.

Whether you’re a clinician or student of the behavioral sciences, this book has everything you need to understand and implement PBT in your work.

Genres: Psychology, Self Help, Nonfiction

240 pages, Paperback

Published December 1, 2021

About the author

Dr. Stefan G. Hofmann is a professor in the clinical program, where he directs the Psychotherapy and Emotion Research Laboratory at the Center for Anxiety and Related Disorders. His main research questions include the following:

Why are psychological treatments, such as cognitive-behavioral therapy, effective for anxiety disorders? What is the mechanism of treatment change, and what are the active ingredients? How can these treatments be improved further?
How can we translate knowledge from basic neuroscience into clinical techniques to enhance therapies for anxiety disorders?
What are the culture-specific expressions of mental disorders, and how can psychological treatments be made more culturally sensitive in order to enhance their efficacy, dissemination, and acceptability?
What are the effects of emotion regulation strategies on anxiety and subjective well-being?
What is the psychopathology of Social Anxiety Disorder? Are there any meaningful subgroups?
His research focuses on the mechanism of treatment change, translating discoveries from neuroscience into clinical applications, emotions, and cultural expressions of psychopathology. He is former president of the Association for Behavioral and Cognitive Therapies, and the International Association for Cognitive Psychotherapy. He is also editor in chief of Cognitive Therapy and Research and is Associate Editor of Clinical Psychological Science. For his most recent books see https://www.amazon.com/Stefan-Hofmann...

Website
http://www.bostonanxiety.org/

http://www.gatestudy.org/home.html

Interests
Social Anxiety Disorder
Psychophysiology of Emotion
Translational Research

Reviews

[Morgan Blackledge · Rating 5 out of 5]

The future of psychotherapy has arrived!

Process-Based Therapy (PBT) is it!

PBT is not (yet another) proprietary model of psychotherapy.

PBT is a revolutionary new methodology.

For a great primer on the methods and philosophy of PBT, read:

Process-Based CBT: The Science and Core Clinical Competencies of Cognitive Behavioral Therapy by Steven C. Hayes, Stefan Hofmann.

Read my review of it here:

https://www.goodreads.com/review/show...

Rather than creating a therapeutic model to treat a DSM diagnosis. PBT seeks to identify the active processes of change contained within the various models and schools therapy, and pair them with the processes of suffering that underly the diagnostic categories and syndromes of so-called mental health ‘disorders’.

“What treatment, by whom, is most effective for this individual with that specific problem, under which set of circumstances, and how does it come about?”

- Gordon Paul

This is the central tenet of PBT.

Although this may sound innocuous.

It’s not.

It’s nothing short of a revolution.

Along with tearing down the boundaries between the varieties of proprietary psychotherapy models.

PBT additionally intends to upend the medical model of psychiatric diagnosis typified in the diagnostic and statistical manual (DSM)

For an excellent primer to the process based transdiagnostic method, read:

Beyond the DSM: Toward a Process-Based Alternative for Diagnosis and Mental Health Treatment by Steven C. Hayes, Stefan Hofmann

You can read my review of it here:

https://www.goodreads.com/review/show...

As if all of that isn’t enough.

PBT integrates (r)evolutionary theory into its methodology in a way that evolutionary psychology has hitherto failed.

For (yet another) excellent primer to the the evolutionary approach to functional/contextual psychotherapy read:

Evolution and Contextual Behavioral Science: An Integrated Framework for Understanding, Predicting, and Influencing Human Behavior by Steven C. Hayes, David Sloan Wilson.

You can read my review of it here:

https://www.goodreads.com/review/show...

Learning Process Based Therapy is a practical application of PBT to clincial practice.

And it legit ROCKS!

This is a must read.

Ignore it and become irrelevant.

5/5 stars ⭐️

[Heiki Eesmaa · Rating 5 out of 5]

In a nutshell, it's a thoroughly thought-out system of functional analysis. Outside of one, there's a lot to it.

[Hugh Simonich · Rating 5 out of 5]

This manual is something I carry with me most of the time as a reference. Hofmann, Hayes and Lorscheid were meticulous in how they organized the material and how they communicated the concepts. It's not so much technically sophisticated as it is conceptually sophisticated. But, the authors took time to repeat concepts and themes worth repeating and gave a number of examples, starting with the basic to increasingly more complex. I found it important to take lots of notes all the way, which helps me when I want to reference back to something I want to be clear about. In summary, this is one of the most well organized, well written and well conceived manuals out there. I was always looking for a new way to conceptualize and document more complete and precise functional analyses and treatment plans. This is what I've been looking for.

[Samuel Kinch · Rating 5 out of 5]

Welcome to the most resounding voice of this new era of individualized evidence-based treatment: process-based therapy. PBT is not a new treatment model, nor anything new at all, really. It is a putting together of old, disparate parts in the fields of psychopathology, intervention science, and evolutionary psychology into a centralized paradigm.

The field of CBT research has strayed too far from the individual. As psychotherapy treatment needed to be established as evidence-based in the American bio-medical system, therapies needed to be standardized and targeted at DSM constructs instead of problems or causes. What has emerged is a field with evidence that therapy works but little understanding of "why" or "how", attached to diagnoses that do not meaningfully capture person-by-person variation in psychopathology.

It's time for a change. Recent basic research on mental illness suggests that mental issues are best represented as networks of interacting nodes representing symptoms and biopsychosocial processes that are attached to the context the individual is in, each person having a unique selection and set of relationships between nodes. This model of mental illness serves as the foundation of PBT, as its goal is to identify the processes of change that will break the cycle of the individual's current network, and to apply micro-interventions, known as treatment kernels to move these processes of change and help the client live a valued life.

A process-based individualized approach is naturally integrative because a focus on the most important biopsychosocial processes for a given client (given their goals and circumstances) and the methods that best move them toward these goals makes these group-level debates about the origin of human suffering unnecessary. It gets at a truth which is self evident to the majority of those who are trained in therapy and have seen clients: different people benefit from different theories and assumptions. The network model allows clinicians to explicitly tailor treatment to the client's unique situation while recognizing that effective interventions need not be limited to any one particular orientation, but rather on the measurable and specific change processes.

The way these networks of interacting processes are created is through a process-based functional analysis, a term from behavior therapy, where the function of the client's thoughts, emotions, attention, sense of self, motivation, behaviors (in the context of their sociocultural and biophysiological domains) are stringently evaluated to see how they are interacting across time in causing persistent cycles of emotional suffering, pain, relationship issues, or a deficit in any valued part of the client's life.

PBT adds another layer to its analysis of interacting processes where other models usually fall short. It sees psychopathology and these processes in evolutionary terms, specifically psychopathology as emerging from "context-specific problems in variation, selection, and retention that can occur in a variety of dimensions and levels." Treatment serves to be the perturbation of the system from maladaptation to adaption, increasing healthy variation of behavior, enhancing proper selection of behavior that will be beneficial in the long run and that is flexible to their changing environment, and involving exercises to ensure retention of adaptive strategies over other less adaptive strategies.

With a proper network created of functional relationships among the client's processes, the clinician can then decide where to intervene, considering primarily centrality of the process and its accessibility to change in order to disrupt negative feedback loops. For example, a simple subnetwork might be: your persistent use of worry as an emotion regulation strategy might have worked in the past to occasionally reduce stress, but currently your use of it at bedtime is making you get worse sleep, which is leading you to be irritable in the morning, which is causing all of these other negative effects, for example, even more stress and anxiety, which causes you to worry even more. Thus, a negative cycle is created. This cycle might be one of many, but the clinician and client may agree that this loop seems to be the most central in the client's problems, so they agree to work on worry.

The micro-interventions in PBT are called treatment kernels, which are change methods designed to alter a specific process of change. Treatment is made up of stacking these various treatment kernels and inquiring how they alter the system as they are applied, altering your approach as information comes in about how the network is changing after their introduction.

One of the most durable findings in emotion and therapy research is that if someone is kept in a long-term cycle of negative emotions, it must mean that the processes that maintain that cycle are being reinforced, as is the case for all behavior that is continually elicited. Unhelpful processes of change almost always reduce stress or anxiety in the short term, but lead to their amplification in the long term. Ruminating, avoiding your fears and conflict, and blaming others will often make you feel better temporarily, and thus are reinforced, leading to us using them more often when we are in a similar state again, no matter if they end up making us more distressed in the long term. In fact, because they worked in the short term, we might even increase our use of them as our psychic pain increases, which only increased because we used these same strategies in the first place. This is one of the most common feedback loops experienced by clients and is exactly the sort of subnetwork that a PBT therapist would intervene on once they saw the role the maladaptive process played.

After first reading the paper the authors of this book published putting forth this new approach, I was hooked. I felt it exactly captured where the field should be heading. It validated my experience of reading all of these therapy models and loving them all, being forced to develop a person-centered approach of how and when to apply each philosophy and theory. PBT filled that uncertain gap, and along with it provided a framework with which to use our most advanced model of mental illness yet. PBT is early in its development. No randomized trials have even been done yet to test it, though they are underway. Aspects of it will need reframing, the field may even need substantial advancement in treatment science before PBT can be properly applied (for example, learning the best kernels for each process, creating an exhaustive list of validated kernels). But, all signs point to this being the future. Our field has been scattered and stratified for a long time, research programs existing in separate theoretical silos, studying constructs and treatments in isolation, an emphasis on noisy (as non-indicative of the underlying cause) topographical symptoms as a diagnostic system instead of focusing on causal mechanisms.

This next decade will be our time to pick up the pieces and form a new path forward, to focus on what matters for the individual and what they want as an outcome from treatment, moving beyond symptom severities and into flourishing, values, and meaning. Most importantly, PBT provides us with a framework to develop a more rigorous clinical science from which we can help people do what we all entered this field for: live a life worth living.

"The aim of PBT is to best understand which core biopsychological processes to target in an individual given their specific goals and stage of intervention, and how to best do so, using functional analysis, complex network approaches, and identification of core change processes developed from evidence-based treatments (Hayes & Hofmann, 2018). The PBT approach involves identifying and addressing core change processes with a focus on the client's concerns." pg 8

"PBT encourages you to choose the most suitable kernel to most effectively move the underling process in a particular client in a given context, and that is not possible if only a very limited set can be deployed. Before even talking to a client, a more traditionally oriented behavior therapist might be more inclined to focus on exposure, stimulus control, and shaping; an ACT therapist on values work and defusion; a traditional CBT therapist on cognitive reappraisal; and so on. That does not make sense. All of these methods can fit within most evidence-based therapy models. What needs to drive kernel use is client need based on a process-based functional analysis." pg 194

"Clients and therapists can both easily be fooled by outcomes alone, and there is a human tendency to grasp at immediate outcomes even if it is not wise in the long run. This is made worse when deliberately creating psychological change because, in the world of outcomes, sometimes things superficially need to get worse before they get better. Metaphorically, if a glass has a thick settled layer of dirt in the bottom, cleaning it will stir things up, and for a few moments the glass will appear to be worse than ever. If a couple needs to have hard conversations about difficult material that spans several years, you can expect that sometimes the conversations will be heated, conflictual, or painful, even if the process itself is broadly healthy. Any evidence-based therapist knows of such examples: extinction bursts, the short relapse often seen in the early stages of cognitive therapy for depression that marks a deeper engagement, difficult emotions during exposure, and so on. In situations likе these, if the client and therapist maintain processes themselves as proximal outcomes, over above short-term outcomes per se, the client is better set up to take steps that feed into an overall pattern of progress." pg 204

[Jeremy · Rating 5 out of 5]

Notes & Quotes:

Full genomic analyses of nearly half a million people have failed to support the relevance of any of the frequently studied genes for common psychiatric disorders (e.g., Border et al., 2019).

Enough is enough. The individual who is suffering cannot be reduced to a gene system, brain disorder, or neurotransmitter imbalance. For decades the development of evidence-based therapy has been based on experimental tests of protocols designed to impact psychiatric syndromes. As this paradigm weakens, a more process-based therapy approach is rising in its place, focused on how to best target and change core biopsychosocial processes in specific situations for given clients with given goals.

Shifting to a PBT framework requires reframing our questions in the field of clinical psychology from “What treatments work?” to “How do treatments work?”

The syndromal approach has been given billions of dollars and decades of time to succeed. And still, it has not. It’s time to change, even without financial support from Big Pharma and mainstream funding agencies.

Syndromal diagnosis (as in the DSM and ICD) does not have known treatment utility. Mediators, on the other hand, have proven treatment utility and are by definition functionally important to clinical outcomes when they are changed by intervention.

In this process-based approach, psychological problems are not person-invariant expressions of a latent disease. Instead, we understand psychopathology as context-specific problems in variation, selection, and retention that can occur in a variety of dimensions and levels. This is the core idea of the Extended Evolutionary Meta-Model, which we base on evolutionary science, adapted to psychopathology and psychotherapy.

We think of treatment as a dynamic change of the complex network from maladaptation to adaptation.

Cognitive factors that increase long-term suffering often produce seemingly positive or at least helpful short-term results.

Cognitively it is easy for clients dealing with mental health struggles to value form over function, meaning they orient themselves more toward what is “true” rather than what is helpful and adaptive.

It is not irrational for the client to select their maladaptive self style, because it serves a function. It is just not working in their favor. It does not help to just point out a client’s maladaptive sense of self. Instead, you need to uncover the function of a specific narrative and offer viable alternative strategies that allow a broader, more flexible sense of self, and thus greater variation, selection, and retention.

it is not irrational for the client to select their maladaptive behavioral style. It is just not working in their favor. As with maladaptive self-styles and motivational styles, beyond merely pointing out maladaptive behavioral styles, you need to uncover the function of a specific behavior and offer viable alternative strategies that allow broader, more flexible behavior, and thus greater variation.

The six dimensions of the Extended Evolutionary Meta-Model (EEMM):
1. Cognition
2. Affect
3. Attention
4. Self
5. Motivation
6. Overt behavior

The two levels of the EEMM:
1. Biophysiological
2. Sociocultural

The processes in a client’s life shape and determine their reality. When the processes are adaptive, the client moves closer to their goals and aspirations, on a path to a healthy, happy, and fulfilling life. When the processes are maladaptive, however, the client moves off course, engages in self-destructive habits, and invites pain, misery, and regret into their life. In process-based therapy, we aim to help the client disrupt old maladaptive processes and instead build new adaptive processes that serve their deeper and more meaningful interests.

Table 8.1 List of Top Mediators: We merely depicted the three most effective mediators per dimension and level as are currently indicated by our data.

therapeutic change is rarely a slow and continuous process. Much more commonly, the system shows only very little initial change, despite considerable effort by the client and therapist. This is because a complex network is very resilient to outside pressure. When the change finally happens, it happens abruptly once the network reaches a tipping point.

Clients never nominated “symptoms” to be the focus of their lives—that came from the well-meaning biomedicalization of human suffering and the gradual cultural change that conception produced. After receiving evidence-based intervention, a relatively large number of patients remain “symptomatic,” and a larger percentage feel that their problems (which often extended beyond classic syndromal signs and symptoms in the first place) were not fully and adequately addressed. On the treatment-delivery side of the equation, it is neither feasible nor meaningful to train clinicians in all of the so-called evidence-based treatment protocols, many of which take many months of training to climb over the hurdles constructed by treatment developers.

Even in these early stages, there is evidence that a modular approach is more efficient and effective than a protocol-for-syndrome approach (e.g., Weisz et al., 2012).

Progressive muscular relaxation training is one of the most empirically studied kernels linked to affect.

The paradoxical effect of suppression is that the harder we try not to be bothered by something, the more this something is bothering us, whether in the form of feelings, thoughts, images, or events in our surrounding environment (such as a dripping water faucet or the ticking of a clock).

The reason why a neutral image of a white bear became an intrusive image was simply because of the attempt to suppress it. The reason for this paradoxical effect is related to the cognitive activity that is required in order to suppress it. In order to not think about something, we have to monitor our cognitive processes. As part of this monitoring process, we focus on the very thing that we are trying not to focus on, which leads to the paradox and, when done regularly, could potentially lead to emotional disorders.

The single most important retention process for psychological processes of change is repetition.

The client is the expert in their own life, but they’re not the expert in processes of change. As we bring in our knowledge of processes of change and fit that knowledge to the client’s life as it is actually lived, we help the person see that they are not broken—rather that a system has ensnared them.

[Luke · Rating 3 out of 5]

The short version:
Coming from an ACT/third-wave psychotherapy perspective, I found this book was a bit clunky and vague. While I like the idea of visually modeling issues and targeting feedback loops with treatment kernels, I found the discussion of the Extended Evolutionary Meta-Model in relation to the processes of change to be quite cumbersome and unclear.

The longer critique:
The first part of the book focuses on the processes of change- which are basically the 6 parts of the hexaflex in ACT. These made sense until they were put next to Hayes' new Extended Evolutionary Meta-Model (EEMM). The book has an important image of a grid where each of the 6 processes (plus the biophysiological and cultural levels) each have a quadrant with the 4 parts of the EEMM (which are variation, selection, retention, and context). This grid looks cool, but I ended up feeling it was somewhat of a nothing-burger.

Early on, the book has the reader choose an issue they're dealing with and then write out how each of the processes is affected within each aspect of the EEMM as they go through each process. However, the EEMM is very poorly explained, each one getting about a one paragraph definition. The pre-written examples given as a guide also make very little sense with regard to each part of the EEMM. They seem arbitrary and showed me the weakness of this new EEMM.

As I was reading, I began to believe that the EEMM were evolutionary concepts being used metaphorically in a behavioral context. However, when I actually when to a training in Philadelphia that Hayes was leading, I asked him if these were meant to be metaphorical adaptations of evolutionary concepts, and he gave a very strong "no" in response. He believed them to be actual evolutionary concepts at work in our behaviors. He basically explained that he believes that we can behave in ways that create positive evolutionary outcomes and that assessing our issues in this light would help to create evolutionarily-adaptive relationship to our inner life.

As cool as it was to talk to Hayes, I still do not think the EEMM is an accurate way of thinking about change processes (I have no gripes about the 6 given, just the EEMM component). There are certainly evolutionary principles at play in change processes, but I feel that this model is quite forced, it just doesn't fit. This isn't quite how these evolutionary principles play out. For example, the book suggests that "selection" pertains to the reasons we select affect, behavior, etc. But in evolution, selection is about the long-term reasons that traits are retained- namely reproduction and survival. There's no way for an individual to manipulate selection as an evolutionary process that leads to "adaptive" change.

I would have found it more interesting to discuss "core human yearning" which I've heard Hayes mention, as foundations of motivation (something like drives) as opposed to creating the flimsy categories into which we can plug the processes.

My other critique is that the book is clearly not third-wave or ACT specific. This took me an embarrassingly long time to realize (especially given that nothing about ACT is in the title). I have little doubt that this book was largely a diplomatic posturing of Hayes and company to allow their process-based theory access into the greater network of CBT therapists. Because of this, the book never quite says what it really wants to say. Certainly processes are at work and can be addressed even in a CBT context, but the whole idea of change processes also undermines modern CBT as we know it, and sadly this is never suggested in the book.

When I saw him speak in Philly, Hayes was not at all ambiguous about his ambition to tear down the DSM and replace decades of norm-based psychotherapy research with what he calls "idionomic" (within-person changes) research. This is a wonderful mission to be on, but I feel that the EEMM is a false flag in this battle.

[Dainius Jakučionis · Rating 5 out of 5]

Knyga yra apie procesu grįstą terapiją. Joje kviečiama pereiti prie kito diagnostinio modelio, kuris nėra paremtas sindromais, o daugiau procesais. Į procesą orientuota terapija, nėra kažkokia atskira terapijos rūšis, tai daugiau modelis pagal kurį dirbti ir jį galima pritaikyti bet kuriai terapijos paradigmai.

Sudaromas procesu tinklas, kurie daro įtaką problemai ir tada intervencijos nukreipiamos tiesiogiai į procesus, kurie yra svarbiausi.

Man patiko toks modelis, nes labai logiškas, plius netoli pabėgęs nuo kognityvinės elgesio terapijos esmės. Kadangi jau anksčiau susipažinau su unifikuotu protokolu nerimo sutrikimams gydyti, tai ši forma nebuvo nauja.

Kas nauja, tai autorių noras patikrinti ir įrodymais pagrįsti gydymo intervencijas. Jie yra atlikę didelę metanalizę apie gydymo intervencijas ir atradę kas labiausiai veikia. Faktas, kad daug dalykų yra iš Acceptance and commitment therapy stalčiaus, nes Steen Hayes yra jos kūrėjas. Bet Stefan Hofman yra ket'istas, tai jie ražiai vienas kitą papildo.

Knyga skirta psichikos sveikatos specialistams pirmiausia, bet joje pristatomas modelis puikia tinka ir kitoms specialybėms: koačeriams, darbe su vaikais, sprendžiant sveikatos problemas.

Tuo šis modelis ir universalus, nes jį galima pritaikyti sprendžiant plataus mąsto problemas. Tiesiog ieškoma procesų, kurie palaiko ir daro įtaką problemai labiausiai ir ten yra daromos intervencijos.

Diagnozuoti nebūtina, nes net ir su ta pačia diagnoze esantys žmonės turi skirtingus palaikančius procesus, tad šis modelis yra labai personalizuotas, čia nėra jokio algoritmo. Tiesiog logika.

[Joseph Jacob · Rating 5 out of 5]

Great book! Views and assesses people from a functional perspective. The way in which the therapy views people should make implicit sense to clinicians, as it gathers most of the data we often gather from thorough clinical intakes. Think of this as a way of succinctly organizing what we've known for years. This approach is part of the new research wave on mental health that'll change the field of psychology for the better.

The other review mentions some excellent books as additional reading. I'd also recommend looking into research written by Ong in the Frontiers of Psychology, and recommend trainings from Div 12 (APA Clinical Psychology) and ABCT to hone your understanding of this fascinating book.

[Cosmin Popa · Rating 5 out of 5]

Very useful for psychotherapists everywhere. The EEMM model, largely described in the book, it is simple, efficient and applicable with clients in a clinical/psychotherapeutic setting. I strongly recommend this book!

[Wojciech Ilski · Rating 5 out of 5]

Phenomenal.

[Lena Pina]

y lo que me gusta a mi una red y que nos adaptemos a la persona...

[C]

A useful book. Was not a huge revelation to me. I think if you have a good grasp of ACT, and you think across levels (emotional, self-concept, biological, etc), and you are skeptical of mental disorders as essential categories, this will not feel all that groundbreaking. I am going to hold onto it and return to it in my practice to see if it makes a difference... Willing to have my mind changed and see how I actually use it in practice.