Do we really need a process‐based approach to psychotherapy?
Authors: Paul M.G. Emmelkamp
Journal: World Psychiatry (2021)

Hayes and Hofmann1 discuss the neglect of processes of change in psychotherapy and the lessons we can learn from process research in the context of “third-wave” cog­nitive behavioral therapies (CBTs). They criticize the notion of psychiatric syndromes and argue that these newer therapies should be considered in the context of an idio­graphic approach to process-based functional analysis. Although I do agree upon several of the arguments the authors put forward, there are a few issues on which my views are some­what different. As to their critic to the latent disease model of psychiatry, they do not discuss the progress which is now being made by the network approach. This approach to psychopathology posits that mental disorders can be conceptualized as causal systems of mutually reinforcing symptoms2. The model has been used over the past decade to examine psychiatric comorbidity and developmental psychopathology, and is being applied to a variety of specific disorders, such as anxiety disorders, autism, depression, post-traumatic stress disorder, eating disorders, psychosis and psychopathy. Hayes and Hofmann argue that in the 1980s the golden era of “protocols for syndromes” settled in, with an ignorance of the therapeutic processes involved in these CBT protocols. This observation may be partly correct, but it is important to note that the CBT movement has always emphasized the role of theory, and of basic research supporting this theory3. Nevertheless, the dominant paradigm has indeed been evidence-based treatment. Expert committees have been providing guidelines for evidence-based treatment of mental disorders, thus “certifying” a given treatment for a given population based on its proven efficacy for that specific mental disorder in randomized controlled trials (RCTs). It should be acknowledged that this approach has led to a number of evidence-based CBT treatments for many mental dis­orders4. At the same time, about 30-40% of patients cannot be successfully treated with current CBT protocols, including “third-wave” CBTs, such as acceptance and commitment therapy (ACT), compassion-focused therapy, mindfulness-based cognitive therapy (MBCT), meta-cognitive therapy, and functional analytic psychotherapy. Although “third-wave” therapies are more experiential and “may lead to positive outcomes for trainees and practitioners”1, there is no robust evidence that they are more effective than classic behavior therapies or “second wave” CBTs5, 6. One important way to investigate mechanisms of change is mediation. Several potential mediators have been proposed in the literature in relation to depression. Cognitive theory states that depression is caused and maintained by dysfunctional cognitions and maladaptive information processing strategies, and depression severity can be reduced by altering the function, content and structure of cognitions associated with negative affect, as is done in CBT. Changing the content of thoughts is seen as an unnecessary step in ACT, as it is assumed that distancing oneself from thoughts is a sufficient and more productive way to diminish the influence of thoughts on behavior. Distancing is achieved through the process of defusion or decentering. In an RCT7, manualized CBT was compared with ACT, and patients in both conditions reported significant and large reductions of depressive symptoms aa well as improvement in quality of life up to 12 months after treatment. Interestingly, dysfunctional cognitions did not only mediate treatment effects of depressive symptoms in CBT, but also in ACT. On the other hand, decentering mediated not only treatment effects in ACT, but also in CBT. Thus, both treatments seem to work through changes in dysfunctional cognitions and decentering, even though the treatments differ substantially. Another interesting issue for further re­search is the role of the therapeutic alliance in CBT and “third-wave” therapies. In an RCT8, the alliance-outcome association in CBT vs. MBCT was evaluated in diabetic patients with depressive symptoms. Because both CBT and MBCT therapists aim to form a therapeutic bond by adopting an open, empathic, accepting, and non-judging attitude towards patients, it was hypothesized that the therapeutic bond was going to predict the subsequent symptom change in both treatments. The results showed, however, that patients’ ratings of the therapeutic alliance predicted depressive symptom improvement in CBT, but not in MBCT. There is a clear need for further studies into the role of the therapeutic alliance in “third-wave” therapies. Although the empirically supported treatment approach is currently still followed by a majority of CBT researchers and practitioners, a growing minority argues for the need to put greater emphasis on individual case formulation based on empirically tested theories instead of treatment protocols. Hayes and Hofmann suggest to study processes of change in therapy using idiographic analysis for nomothetic purposes and to treat the individual patient “by understanding the process-based complexity of his/her problem and applying tailored intervention strategies”1. But, what is the evidence that individualized treatment based on functional analysis and case formulation is more effective than standard protocolized treatment? Hayes and Hofmann cite two studies to support the notion that treatment modules to target person-specific maladaptive processes of change are more effective than glob­al protocols. In one of these studies9, an individualized approach was found to be more effective than standard treatment in children with behavioral problems. However, only about one half of children in the control condition actually engaged in behavioral health services. To test the study hypothesis, the individualized approach should be compared with an evidence-based treatment for behavioral problems. Actually, there is no robust evidence for a superior effectiveness of treatment based on functional analysis compared with manualized evidence-based treatments2. Although there are clear advantages associated with an individualized approach, if proven effective, there are also disadvantages. First, the success of the therapy will largely depend upon the therapist’s creativity. Moreover, an individualized treatment approach is certainly much more difficult to learn and practice than a manual-based, standardized, evidence-based intervention.