What is the future of CBT? For two leading researchers, the future could be that science and practice goes beyond the “alphabet soup” of branded therapies, to process based CBT.
Steven Hayes and Stefan Hofmann have shared a fascinating video, discussing their views on the third wave, process based CBT, and the future of evidence-based therapy:
They speculate there may even be a “post-CBT” future.
As processes of change across therapies from various traditions are understood, there may be greater opportunities to “create bridges rather than walls” in the empirical understanding of how people change, and thrive.
It is evident from their conversation that the bridge building has definitely been happening – a cognitive therapist and researcher (Hofmann) agreeing on many points with a contextualist (Hayes), while also acknowledging their philosophical differences.
[This is such a difference from the conversations that I saw in 2008, when Stefan Hofmann graciously participated in the ACBS World Conference held in Chicago. At that conference, it was almost maddening – for someone with a foot in both CBT camps – to see that, while there were areas of agreement, Hofmann could not acknowledge the importance of philosophical differences, and why
radical behaviourists functional contextualists would choose differing independent and dependent variables to someone working within a cognitive perspective.
It is my dearest wish that conversations in CBT circles show the same understanding that Hayes and Hofmann model – no more cheap shots, straw men and silly characterisations of perspectives based on differing philosophies, and instead interactions of genuine curiousity and openness]
For me, the Hayes and Hofmann conversation also works as additional material to two of their recent, important publications.
The first is their paper, “the third wave of cognitive behavioral therapy and rise of process-based care“, published in World Psychiatry in September 2017.
This brief paper outlines the essence of their position – that the third wave (note that Steve Hayes is talking about it in the past tense in the video!) led to a:
- greater recognition of philosophical assumptions in the science of CBT;
- greater focus on moderators and mediators of change, and the development of interventions that promote functionally important pathways of change that cut across problems and syndromes (transdiagnostic processes).
These trends in the science of CBT have also led to changes in perspective, which may lead to greater integration across areas:
As a purely syndromal focus weakens and a process focus strengthens, human psychological prosperity and the thriving of whole persons, not merely psychopathology, is also becoming more central. Behavioral and mental health is ultimately about health, not solely the absence of disorders.
This set of changes is accelerating a transition in evidence-based care toward a process-based field that seeks to integrate the full range of psychosocial and contextual biological processes. Such a field is so broad that it stretches the very term CBT almost to a breaking point and we would not be surprised if that term soon wanes in importance.
The second important publication is newly released textbook, “Process Based CBT: The Science and Core Clinical Competencies of Cognitive Behavioral Therapy”, published in January 2018 by New Harbinger Publications.
I am currently reading “Process Based CBT”, and thinking through the book’s implications as a clinician, researcher and as a teacher of clinical psychology. Already I can see new ways of teaching and supervising others in CBT, based on the ways processes of change are discussed in the book.
In my view, this is the first major modern CBT textbook that presents a serious integration of the cognitive and contextual perspectives in clinical psychology. It reflects consensus views of contemporary competencies in CBT and likely directions the field is heading in.
While there have been previous CBT textbooks that have described cognitive therapy and acceptance and commitment therapy models and techniques, this is the first attempt at presenting the pluralism of contemporary CBT (including philosophy of science, assumptions of models, links to learning theory, neuroscience and evolution) in a way that doesn’t call for practitioners to sign up to one side or another.
It is truly integrative and certainly beyond “therapy brands”, with discussions of how various common CBT methods, such as reappraisal, decentring, exposure, and behavioural activation can be understood from differing perspectives.
For a mainstream text, the even-handed presentation of this pluralism is excellent.
The book even provides the analytic tools to help readers grasp when arguments based on philosophy are useful or not (e.g., Sean Hughes’ terrific chapter on philosophy of science in clinical psychology).
The video provides more background on this book: as Hofmann and Hayes describe, “Process Based CBT” is an evolution rather than a revolution. They discuss how behaviour therapy may have lost it’s roots in processes and functional analysis, by historically embracing DSM syndromes and packages of interventions, which brought with it latent disease model notions of psychological functioning. I got the sense that while empirical development of CBT has been successful within this syndrom/ package approach, it has also led to a weakening of the link between basic science and applied research.
They share in their conversation that a process-based approach to CBT and to therapy writ large, moves beyond the validity problems of diagnosis, and returns to a central focus on understanding processes and mechanisms. This focus can join together processes from different therapies, as the analytic tools are now available to researchers to understand better how change occurs. It is exciting to hear Hayes and Hofmann discuss the implications of coherence across levels of analysis, joining biological and psychosocial factors, considering evolution science terms of variation, selection and retention in considering changes processes etc.
This conversation between colleagues, friends, and occasional intellectual combatants, is thoroughly recommended!
What’s your perspective? Do you think that a process based approach to therapy is the future of science and practice?
Feel free to comment!
Superb post, fantastic conversation worth watching the whole 55mins. Can’t wait for the edited volume arising from the Boston Conference to emerge – including NIMH folks and more. Thanks for linking, incl the World Psychiatry paper, Process-Based CBT text AND Sean Hughes chapter – all super, inspiring stuff 🙂
I hardly read CBT material, and have not read ACT, so I may be ignorant and misunderstand what has been written and proposed. However, I smile while listening to the video. NLP has been developing and teaching pure process based therapy since the 1970s. If I cannot post links here, one can go to youtube and search Steve Andreas & Phobia Cure; and then the 25 yr follow up. Steve demonstrates the very reliable process for dealing with a woman’s traumatic memory in less than 9 minutes. It is totally process based in that one does not even know the content until the end. People overcome years of suffering in minutes. Like Steve, I usually do not ask the person to tell me details of their trauma. Most times it works.
Phobia Demonstration with Lori, who had an intense phobia https://www.youtube….h?v=mss8dndyakQ
Follow up interview with Lori 25 years later https://www.youtube….h?v=TjjCzhrYJDQ
Steve, with his wife, Connirae went on to build on early NLP techniques. Again, so many are purely process techniques, where content can be minimal. There are techniques for dealing with grief, shame, regret, anger/forgiveness, compulsions and others. These take minutes. Like the phobia video above, one knows immediately if the technique worked or not. It does not require homework, or practice. If it worked, it usually lasts.
NLP has not got a solution to everything, but there is much that psychology seems to be unaware of. Steve Andreas has many videos demonstrating his therapy, both with single client sessions, and more recently with PTSD.
I don’t consider Hayes a functional contextualist anymore. They use mentelistic and dualistic language to describe the processes. But the problem with a dualistic approach to processes which are happening in a non visible and mental space. If processes are happening in a space which is not visible then you can’t influence them either. That’s exactly what their doing and that is a fundamental mistake.
It is possible to work in a space where the processes are not visible and influence them thanks to the properties of language, and its ability to approach or distance us from (present) contigency. Behavior can be influenced, both in a dysfunctional and functional way, thanks to the language’s ability to establish arbitrary delivered relations within frames (frames) that can be manipulated directly.
Processed- Based CBT as a conceptualisation of mechanism of change in evidence based psychological therapies is an opening and uniting way to consider reintegrating the fragmented state of CBT and potentially enhancing efficacy. In individualised formulation driven CBT (CMI) there is the potential to augment the models with additional active processes that address additional processes, LSE, Perfectionism, secondary goals, psychological inflexibility and unwillingness. It also allows CBT processes into the ACT pantheon of processes and specific first and second wave effective treatments can be treated in an evidence based way. i.e. PTSD, Specific Phobia, social anxiety, OCD, Panic. GAD maybe more MCT treatment approaches. In unifying CBT new research protocols may allow in attentional training, diaphragmatic breathing, breathing, and metacognitive awareness, alongside diffusion, willingness, allowing (acceptance), letting go of tension, bracing. The challenge may be in mapping contextually based unhelpful and helpful mechanisms of maintenance and change.
As a psychotherapist practicing CBT for many years, and often getting stuck or not being able to connect with clients who were not capable of cognitive restructuring, ACT was a great way to expand and meaningfully tailor processes of change to client needs. Yet I could not completely let go of CBT techniques and CBT model, at least in the initial sessions to help clients identify and understand thoughts, feelings and behaviour, and their association. So Process based CBT is highly validating of a clinicians true needs and struggles in working with clients. Thank you. 🙂