Cognitive behavioral therapy, process‐based approaches, and evolution in the context of physical health
Authors: Lance M. McCracken
Journal: World Psychiatry (2021)

Hayes and Hofmann1 describe how the context around cognitive behavioral therapy (CBT), a context that has supported significant success for many years, may now be stifling progress1. They say that it is now time for a new strategic approach. In their words, a focus on syndromes, diagnostic categories, and the development of treatment protocols based on studies of group data, has dominated the field of mental health, perhaps for too long. New developments in CBT provide the chance to refocus on the unique problems that individual people face, and on custom-delivered methods targeting empirically-based processes of change, rather than packages of methods prescribed by a protocol. This evolution of CBT toward more person-specific and process-focused delivery presents an opportunity to transform mental health care. Clearly this ought to apply to physical health care as well. While there is no quibbling with the authors’ reminder that depression is one of the world’s leading causes of disability, it is also worth pointing out that the top ten contributors to the global burden of disease in adults include low back pain, headache disorders, ischemic heart disease, and stroke2. In fact, each of these conditions actually surpasses even the substantial disease burden of depression in people aged 25 to 49, and, excluding headache, in people aged 50 to 74. What makes this relevant is that each of these conditions involves a substantial role for modifiable cognitive and behavior­al processes. In each case, risk factors that lead to the development and maintenance of these conditions, and the processes that translate the experience of these conditions into impacts on daily functioning, and years lived with disability, can be substantially modified with forms of CBT. These include newer, “third wave”, formse.g., 3, 4. The point is that, even with the great need for improving mental health worldwide, we should not lose sight of the need for cutting across the assumed border between mental and physical health, to consider the opportunity for world health as a whole. This boundary is called “assumed” because so-called mental and physical health conditions are highly comorbid, certainly share many risk factors, worsen under many of the same influences, and improve with application of many of the same kinds of treatment methods. Individual behavior is an extremely powerful common pathway toward general health and well-being, as well as an outcome or indicator of these, more so than we often think. In some ways, the contexts of physical health provide easier access for person-specific and process-focused approaches. The door is already open to a degree. When people have chronic pain, headache, heart disease, cancer or diabetes, as examples, they already have a diagnosis and clearly their focus and the focus of clinicians, at least in part, is on addressing the impacts of these conditions. That being the case, there can be less an urgency around assigning another diagnosis in the realm of mental health. Also, a focus on multiple outcomes, on healthy behavior, on functioning well and well-being, and not just on symptom reduction, is already a relatively ordinary focus in the domain called clinical health psychology or behavioral medicine, essentially the domain where CBT operates in physical health. This appears particularly true in the context of chronic diseases. Seizing the opportunity for enhancing physical health through the application of new CBT methods is not without potential impediments. For example, in chronic pain management, particularly in specialty centers, CBTs are traditionally delivered in groups. Also, in most health care research, studies are based on group data, normally collected at relatively infrequent intervals, before treatment, immediately after treatment, and at a later follow-up. This focus on groups clearly presents significant difficulties, if the aim is highly individualized treatment. Group delivery and a focus on group means are not likely to yield the knowledge needed, if the need in knowledge is how to customize the delivery of treatment components and to selectively target only relevant process of change for each person5. The infrequent assessment of outcomes, and presumed mediators of outcome, if included, is unlikely to detect complex, multivariate, bidirectional, and highly individual processes of change6. In the future, we will need to more frequently employ single case experimental designs with intensive longitudinal data gathering. As well as needing to build a library of theoretically derived and empirically-based therapeutic processes of change, we will also need to harness new technologies for data gathering and analysis. These data will most likely be collected by hand-held “smart” devices that include a new generation of outcome and process measures which are brief, individually-relevant, and sensitive to change. Analyses of these data will then allow analyses of potential mechanisms of change in highly individual ways, and meta-analyses of these case data will allow the development of new general principles, and a science of truly personalized therapy will finally emerge6. Another possible impediment to change in CBT for physical health resides in the predominantly interdisciplinary context of much of this work. When working in interdisciplinary teams, it seems necessary that all members know what the others are doing and why. With the appearance of new approaches, some members of teams may express frustration, such as to say that now we must train colleagues all over again. While this frustration might be understandable, change will come, approaches will evolve. And this is not a break from past learning, but an extension. Moreover, the alternative – staying the same – is both undesirable and ultimately impossible. Important steps are already being made. Implementation of “third wave” therapies well-suited to process-based delivery is expanding rapidly in physical health contexts, as demonstrated in published ran­domized controlled trials dealing with bowel disease, cancer, chronic pain, dialysis, diabetes, epilepsy, exercise, headache, HIV, multiple sclerosis, sleep, smoking, tinnitus, and weight loss7. A focus in research on predictors and mediators of outcome is becoming commone.g., 8. And in the wider field of CBT there are now an increasing number of studies that employ single case approaches. These studies are now able to analyze processes of therapeutic change, using methods for gathering data daily, including ecological momentary assessment. They can also apply methods for analyzing process and outcome data that allow individualized targeting of key functional processes of change, including factor analysis and network analyses of ­individual data9. While there is progress, at the same time there is much to do so that these developments will continue. We need to produce new knowledge, new applications of current technology and new technology, and we need to educate and train. Perhaps in small steps, process-based therapy designed around the specific needs of individual people, for both mental and physical health, is becoming a reality.