A Process-Based Approach to CBT E-Book

Michael Svitak

• Herausgeber: Hogrefe Publishing
• Kategorie: Fachliteratur
• Sprache: Englisch
• Veröffentlichungsjahr: 2024

Beschreibung

Using a process-based approach to personalize CBT for better successPresents a unique dynamic approach to CBTShows how to implement this approachProvides downloadable toolsThe process-based approach to cognitive-behavioral therapy (CBT) is a unique method for understanding psychological problems as complex networks of interacting processes. It allows therapists to grasp the individuality, complexity, and dynamics of psychological disorders – things that often get missed in diagnosis-oriented approaches. The authors, both experienced researchers and practitioners of this method, explore how understanding these complex networks enables therapists using CBT to focus on the core processes responsible for a person's suffering.First, the reader is shown how emotional, cognitive, behavioral, and somatic processes interact in maintaining maladaptive states and how this approach identifies the points at which therapeutic interventions can be applied to achieve maximum leverage. This is followed by guidance on implementing the approach in practice, including addressing diagnostic issues, to create an individual process-based model network for selecting the right evidence-based interventions. The process-based approach forms a connecting foundation that combines classical CBT with third-wave approaches (acceptance commitment therapy, schema therapy) and integrates helpful recent developments in psychotherapy research, such as evolutionary theories. Practitioners will find the downloadable tools in the appendix invaluable for their clinical practice. This book is of interest to clinical psychologists, psychiatrists, psychotherapists, mental health practitioners, students, and trainees.

Leseprobe

Michael Svitak

Stefan G. Hofmann

A Process-Based Approach to CBT

Understanding and Changing the Dynamics of Psychological Problems

About the Authors

Dr. Michael Svitak, born 1969, studied psychology in Regensburg (Germany) and Reading (UK), receiving his doctorate at the University of Salzburg (Austria) in 1998. Since 2004, he has been head psychologist at the Center for Behavioral Medicine at the Schoen Clinic Bad Staffelstein and also a supervisor and trainer for process-based cognitive behavioral therapy.

Prof. Dr. Stefan G. Hofmann, born 1964, studied psychology in Marburg, receiving his doctorate in 1993. Since 1999, he has been professor of psychology at the Department of Psychological and Brain Sciences at Boston University and has had tenure at Boston University since 2003. Since 2021, he has been Alexander von Humboldt Professor, LOEWE Top Professor, and head of the Translational Clinical Psychology at Philipps University Marburg. His research and work interests are mechanisms of treatment change and emotion regulation, and cultural expressions of psychopathology.

Library of Congress Cataloging in Publication information for the print version of this book is available via the Library of Congress Marc Database under the LC Control Number 2023949436

Library and Archives Canada Cataloguing in Publication

Title: A process-based approach to CBT : understanding and changing the dynamics of psychological

problems / Michael Svitak, Stefan G. Hofmann.

Other titles: Prozessbasierte Psychotherapie. English

Names: Svitak, Michael, author. | Hofmann, Stefan G., author.

Description: Translation of: Prozessbasierte Psychotherapie: Individuelle Störungsdynamiken

verstehen und verändern. | Includes bibliographical references.

Identifiers: Canadiana (print) 20230558208 | Canadiana (ebook) 20230558216 | ISBN 9780889376281

(softcover) | ISBN 9781616766283 (PDF) | ISBN 9781613346280 (EPUB)

Subjects: LCSH: Cognitive therapy. | LCSH: Psychotherapy. | LCSH: Mental illness—Treatment.

Classification: LCC RC489.C63 S8513 2023 | DDC 616.89/1425—dc23

© 2024 by Hogrefe Publishing

http://www.hogrefe.com

Cover image: © shutterstock.com / optimarc

The present volume is a translation of M. Svitak and S. G. Hofmann, Prozessbasierte Psychotherapie (ISBN 978-3-8017-3071-0), published under license from Hogrefe Verlag, Germany. © 2022 by Hogrefe Verlag.

The authors and publisher have made every effort to ensure that the information contained in this text is in accord with the current state of scientific knowledge, recommendations, and practice at the time of publication. In spite of this diligence, errors cannot be completely excluded. Also, due to changing regulations and continuing research, information may become outdated at any point. The authors and publisher disclaim any responsibility for any consequences which may follow from the use of information presented in this book.

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Format: EPUB

ISBN 978-0-88937-628-1 (print) • ISBN 978-1-61676-628-3 (PDF) • ISBN 978-1-61334-628-0 (EPUB)

https://doi.org/10.1027/00628-000

Citability: This EPUB includes page numbering between two vertical lines (Example: |1|) that corresponds to the page numbering of the print and PDF ebook versions of the title.

Contents

Foreword

Preface

Part I  Theoretical Foundations

1  Limitations of Diagnosis-Oriented Psychotherapy

1.1  Inadequate Conceptualization of Mental Disorders

1.2  Complexity and Dynamics of Mental Disorders

1.3  Somatic or Latent Disease Model

1.4  Applying Linear Thinking to Complex Systems

1.5  Heterogeneity of Diagnoses

1.6  Nomothetic Versus Ideographic Explanatory Models

2  Theoretical Foundations of Process-Based Approach

2.1  Process Level: Space Between Narrative and Diagnosis

2.2  Processes: The Origins of Behavior Therapy

2.3  Allostasis Model

2.4  Psychopathology: Complex Dynamic Networks

2.4.1  Time Dimension: Variability Over Time Makes Processes Visible

2.4.2  Stable Networks: Homogeneous and Strongly Interconnected Elements

2.4.3  Development of Mental Disorders From a Network Perspective

2.4.4  Transdiagnostic Network Structures

2.5  Psychotherapy: Network Changes at the Process Level

2.6  From Sick to Healthy: Overcoming Network States

2.7  Typical Process Patterns Causing Psychopathology and Suffering

2.7.1  Unproductive Process Loops

2.7.2  Missing Balancing Feedback Loops

2.7.3  Maladaptive Inhibitory Control Processes

2.7.4  Bottlenecks and Tipping Points

2.7.5  Core Dimensions With Strong Influence on the Overall System

2.7.6  The Inaccessability of Positive Emotional Network Structures

2.7.7  Difficulties in Emotional Processing Hinder Learning Processes

2.8  Examples of Process-Based Disorder Models

2.8.1  Comorbidity of Depression and Anxiety

2.8.2  Prolonged Grief Disorder

3  Process-Based Models of Mental Disorders

3.1  Diathesis-Stress Model

3.2  Process-Based Diathesis Model

3.3  Process-Based Complex Network Model

4  Core Processes of Psychopathology

4.1  External Demands or Stressors

4.2  Vulnerability Mechanisms

4.2.1  Neurophysiological Level

4.2.2  Emotional Level

4.2.3  Behavioral Level

4.2.4  Cognitive Level

4.2.5  Level of the Self

4.2.6  Attachment and Relationship Level

4.2.7  Specific Constructs

4.3  Response Mechanisms

4.3.1  Behavioral Core Processes

4.3.2  Cognitive Core Processes

4.3.3  Emotional Core Processes

4.3.4  Motivational Core Processes

4.3.5  Social and Interpersonal Processes

5  Psychotherapy From a Process-Based Perspective

5.1  Core Processes of Psychotherapy

5.2  Process-Based Therapeutic Stance

5.2.1  Capturing Complexity With All Perceptual Channels

5.2.2  Collaborative Empiricism

5.2.3  Informed Consent

5.2.4  The Therapist as a Person

5.2.5  Dealing With Errors and Uncertainties

5.2.6  Flexibility and Loyalty to the Common Treatment Rationale

5.3  Evaluation of Adaptivity Based on Evolutionary Principles

5.3.1  Variability

5.3.2  Selection

5.3.3  Retention

5.3.4  Context

5.3.5  Physiological and Social/Cultural Level of Analysis

5.3.6  Application of the Principles of Evolution in the Psychotherapeutic Context

Part II  Applying the Process-Based Approach in Practice

6  Phases of Process-Based Psychotherapy

Phase 1: Multidimensional Diagnostic of Relevant Processes

Phase 2: Core Processes: Creating a Process-Based Diathesis Model

Phase 3: Developing an Individual Process-Based Complex Network Model

Phase 4: Defining Therapy Goals and Evaluating Readiness for Change

Phase 5: Selecting and Implementing Interventions

Phase 6: Monitoring and Reevaluation of the Perturbation Model

7  Phase 1: Multidimensional Diagnostics of Relevant Processes

7.1  Spontaneously Reported Symptomatology: Recognizing Processes

7.2  Specified Exploration of Conditional Factors at the Process Level

7.2.1  Exploring External Coping Demands (Threats)

7.2.2  Understanding Internal Coping Demands

7.2.3  Identifying Vulnerability Mechanisms

7.2.4  Identifying Problematic Response Mechanisms

7.2.5  Understanding the Effects and Consequences

7.3  Process-Oriented Functional Analyses

7.3.1  Selecting Relevant Problematic Situations

7.3.2  Process-Based Functional Analysis

7.4  Longitudinal Analysis of Symptom Development (Life Chart)

7.5  Treatment History

7.6  Including External Perspectives

7.7  Context Analysis: Protective Factors and Risk Factors

7.8  Process-Oriented Assessment of Psychopathology

7.9  Using Traditional Diagnostic Methods to Identify Relevant Processes

7.9.1  Established Test Procedures

7.9.2  Questionnaires for Specific Process-Oriented Constructs

7.9.3  Neuropsychological Testing and Biofeedback Methods

7.10  Further Process-Orientated Methods: Self-Observation and Visualization Instruments

7.10.1  Recording Emotion Regulation Processes

7.10.2  Recording Cognitive Processes

7.10.3  Recording Behavioral Processes

7.10.4  Recording of Somatic Processes

8  Phase 2: Developing a Process-Based Diathesis Model

9  Phase 3: Developing an Individual Process-Based Complex Network Model

9.1  Practical Procedure for Developing a Complex Network Model

9.2  Evaluating the Adaptivity of Network Patterns Using the Extended Evolutionary Metamodel

9.2.1  Variability

9.2.2  Selection

9.2.3  Retention

9.2.4  Context

9.3  Practical Example

9.3.1  Individual Process-Based Complex Network Model

9.3.2  Complexity

9.3.3  Core Dimensions

9.3.4  Accessing Adaptivity

10  Phase 4: Defining Therapy Goals and Creating Readiness for Change

10.1  Defining Global Therapy Goals

10.2  Defining Targets of Change at a Process Level

10.3  Capturing Readiness for Change

10.3.1  Determining the Current Phase of Motivation

10.3.2  Cost-Benefit Analysis for Change

10.3.3  Determining the Type and Duration of Motivation Required for Change

10.3.4  Subjective Prognosis of Success Limits Change

11  Phase 5: Selecting and Implementing Interventions

11.1  Selecting Interventions

11.1.1  Defining Effective Dimensions to Target

11.1.2  Selecting Interventions to Change Core Processes

11.1.3  Planning the Sequence of Interventions

11.1.4  Weaken the Maladaptive Network or Strengthen the Coping Network?

11.2  Implementing Interventions

12  Phase 6: Monitoring Change and Constant Reevaluation

12.1  Negative Versus Positively Oriented Monitors

12.2  Critical Thresholds and Bottlenecks in Therapy

12.3  Criteria for Ending Therapy

13  Outlook

References

Appendix

Worksheets 1–18

Notes on Supplementary Materials

|5|Foreword

Why a Process-Based Approach Is the Next Logical Step in CBT

A process-based vision is not new to cognitive behavioral therapy (CBT), but our field has been through so many years of narrowing, caused in part by our own success, that today it can feel as though it is entering the field orthogonally rather than as a historical foundation. An evidence-based approach to psychological intervention began with the task of applying well established principles to the problems of an individual, but it was not long before the central task came to be to diagnose a problem based on signs and symptoms, to categorize these under a specific mental disorder label, and to apply a manualized set of interventions aimed at reducing those signs and symptoms. CBT was spectacularly successful in that task, and that approach helped CBT prosper world-wide. But a sense of stagnation has now arrived, due in part to the galling fact that our effect sizes are not increasing (Hayes, Hofmann, & Ciarrochi, 2023). We need a new way forward.

A process-based approach returns our field to the difficult but exciting task of modeling the complex interplay of affect, cognition, attention, sense of self, motivation, and overt behavior, along with processes in the sociocultural and biophysiological domains, in order to understand why problems arise and persist and how to resolve client problems and promote greater prosperity. Instead of the fruitless pursuit of latent mental diseases, our field is moving towards a new vision in which it is the task of the CBT clinician, and all evidence-based clinicians, to answer this question: “What core biopsychosocial processes should be targeted with this client given this goal in this situation, and how can they most efficiently and effectively be changed?” (Hofmann & Hayes, 2019, p. 38).

The book you have in your hands takes a sober look at the situation and draws on the now large body of basic and applied knowledge regarding process of change, from basic science to third-wave methods in CBT, and applies it to the radically “transdiagnostic” task of answering the key “what,” “why,” and “how” questions that have always been part of our professional and scientific journey. Why did this problem develop in the first place? What are the goals of the client and what is needed to initiate change? How will change become self-amplifying or be maintained?

This well-written book is not a cookbook of methods, nor it is theoretical tome. It is a practical process-based road map that describes in a step-by-step fashion how to take a process-based approach to CBT, and how to so deeply understand the dynamic of your clients’ psychological problems that they can be changed in a systematic fashion that is both strategically sensible and empirically sound.

While traditional evidence-based therapy often employs a nomothetic approach, aiming to generalize from a sample population to individual cases, a process-based approach is idionomic in nature, focusing on the unique characteristics of individual clients but then generalizing them as warranted to nomothetic principles, provided always that the clarity of the individual is thereby increased or at least not compromised. A client is never |6|treated as an “error term” in this approach, nor in this volume. Each unique person is still unique, and a process-based approach sets as its goal that the person will be seen even more clearly and heard even more thoroughly by the analytic steps taken.

That is not mere rhetoric. You will sense as you use the methods this book contains that they bring you as a provider closer to the idiosyncratic details that often get overlooked when we focus on latent disease entities. You will better understand your clients and the options you have to create progress will be more illuminated.

A process-based approach moves practitioners away from a static, linear, pauci-variate model of psychopathology to one that is dynamic and network-based. A process-based approach accommodates complex models of causality, such as feedback loops and dynamic systems, which capture the nonlinear and multicausal nature of psychological phenomena. This approach enhances our understanding of why treatment works when it does and sets the stage for more targeted, kernelized, individualized therapeutic strategies.

This process-based approach recognizes and enriches the strengths of CBT. Svitak and Hofmann are not saying “let’s discard our CBT methods.” Instead, they are saying “let’s understand why our interventions work, for whom, and under what circumstances.”

Pursuing a process-based approach is akin to training to be a master chef who knows not just the recipe but also the intricate interactions between ingredients – the subtleties that transform a dish from good to great. It seeks not to replace CBT but to evolve it, to move from a focus on what we should do in therapy, to how and why we should do it, in a way that is attuned to the individual complexities of each client. It is an invitation to be more nuanced, more flexible, and, ultimately, more effective in our practice.

This well-written book lays out the problems of traditional diagnosis and its excessive focus on a nomothetic search for latent diseases, and instead proposes a more idiographic, complex dynamic network approach to psychological difficulties. This shift is not an abstract academic matter – it is an urgent call to action and attention by researcher and practitioners alike. The subpar remission rates in intention-to-treat samples highlight a daunting truth: We are only partially effective in our therapeutic endeavors.

As network thinking is initially explored by the authors it becomes evident that it matters how we conceptualize and analyze client problems, and their predisposing, contextual, sustaining, and protective or positive factors. The authors detail a system of understanding and tracking the major known processes of change, and how they might be impacted by the core processes of psychotherapy.

English readers might be surprised to find that a forward looking and very well-known German psychotherapist, Klaus Grawe (1995), long ago laid out a vision of a scientifically based psychotherapy that focused on relevant processes of change rather than on diagnoses and therapeutic procedures. Details of his theory have not been well validated but his work makes it easier to understand how a process-oriented approach can indeed provide an umbrella for the systematic application of evidence-based methods that modify the processes establish and maintain a pathological network. It also explains why the German psychological community has been particularly welcoming to a process-based approach and is assuming a leadership role worldwide in this area.

A strength of this volume is the detailed way that these core ideas are linked to phases of process-based psychotherapy, from recognizing processes and exploring their determinates, to creating a process-oriented functional analysis and repeatedly assessing client progress. This is a practical volume that has already gone through the hard test of application in systems of care. When the dynamics of a case are clear, a rational kernel-based |7|intervention plan can be uniquely constructed and targeted toward client needs, and an iterative virtuous cycle of monitored steps towards goal attainment can ensue.

In the latter parts of the book, the focus on practical application, assessment tools, and real-life examples offers a seamless bridge from theory to practice. Therapists are not just offered abstract concepts but actionable steps, forms, measures, and strategies to bring the process-based approach to life within the therapy room and system of care.

We have to acknowledge that while meta-analyses already show that taking a more personalized approach produces small but significant therapeutic gains (Nye et al., 2023), a lot remains to be done empirically. But this approach is more a model of how to apply existing knowledge than a radically new set of proposals disconnected from our existing research base and therapy traditions. You can still be you in a process-based approach and the methods that matter can still be used. What is different is your ability to do so is guided by process-based evidence that has been there all along, unseen because of our excessive latent disease focus.

Each era of psychotherapy brings with it new insights, tools, and challenges. The shift towards a process-based approach, as articulated by Svitak and Hofmann, is not just the next phase of this journey but shows every sign of being a transformative leap. It holds the promise of deeper understanding, more effective interventions, and the potential to touch and transform countless lives.

Steven C. Hayes, PhD

Foundation Professor of Psychology Emeritus

University of Nevada, Reno, NV

|9|Preface

If you can add up, that is often enough to deal with most basic requirements in everyday life. If the requirements become more complex, the concept of adding up becomes limited. Then it’s helpful when you learn to multiply and divide to understand and deal with more complex demands. Suddenly, previously complicated tasks seem easy. The incomprehensible takes on a logic that helps you to keep track of more complex tasks and to find solutions.

From this point of view, we psychotherapists have become very good at adding up, but we reach our limits with the high degree of complexity we are confronted with in treating our clients, especially when mental disorders do not only occur once but recur or manifest themselves in combination with other disorders. The remission rate in intention-to-treat samples is usually below 50 % (Cuijpers et al., 2010; Spijker et al., 2013). (Intention-to-treat means that the data of all clients who were previously intended to be treated are also evaluated afterwards. This ensures that the data of clients who do not benefit from a treatment and drop out are also evaluated.) We could blame the 50 % failure rate on our clients, but perhaps our current models of mental disorders limit the effects of psychotherapy because we cannot grasp the complexity with our existing models. Perhaps our models of psychological suffering do not adequately represent the complexity and dynamics of mental problems, or perhaps we are focusing on the wrong aspects. Where do we find the complexity and dynamics of mental disorders if they are not sufficiently to be found in the current causal models of disorders? This book is all about focusing on the level of relevant processes, instead of looking at symptoms and syndromes that are often merely a result of these underlying processes. This helps us understand the dynamic interactions of multidimensional processes clients are suffering from in more depth and opens up perspectives for change that are concealed on a symptom level.

From the Symptom Level to the Process Level

Normally, cognitive, emotional, behavioral, motivational, and interactional processes work well together so a person can cope with ongoing demands. In a healthy state, we are as unaware of these coordinated background processes of the mental adaptation apparatus as we are of the work of our PC’s operating system. We only become aware of them when the initiated psychological processes aren’t successful and either lead into processing loops that generate more and more information or result in processes working against each other. We perceive these underlying adaptation processes gone rogue as a kind of psychological strain, draining psychological energy until we fear the mental system goes haywire or collapses. When clients are asked what percentage of their mental energy is being absorbed by unsuccessful inner processing attempts to solve their problems, many respond: “Over 90 %. And it feels like it’s getting more all the time.”

|10|From a process-based perspective, mental disorders are the result of these multidimensional adaptation processes gone wrong, so that a formerly healthy state transforms into a system state experienced as stressful (Hayes et al., 2015). So, while we are used to focusing on the level of symptoms, the dynamics and complexity of the regulation process is found at a level “below” the symptoms: at the level of processes, where processes interact with each other to react to demands to the adaptation apparatus. The visible symptom level is merely the result of interacting processes.

Process-based approaches (Borsboom et al., 2011; Hayes et al., 2015; Hayes & Andrews, 2020; Hayes & Hofmann, 2018a, 2018b, 2020; McNally, 2016; Robinaugh et al., 2016) have the potential to add promising new dimensions to our understanding of the complexity and dynamics of mental disorders. They view psychopathology as dynamic networks in which interacting processes are responsible for maintaining pathological system states (Hofmann et al., 2016).

In the first part of the book, we present the most important theoretical foundations of the process-based approach and explain what a process-based view means for our conception of mental disorders and their treatment. In the second part of the book, we describe the practical application – step by step through the phases of a therapy. We hope this approach will inspire your work with clients as it did us. After we spent some time considering the implication of a more process-based approach, we began to look at mental disorders more through a process lens. This helped us to look beyond the content of the disorder and identify the relevant underlying process patterns. This has broadened our understanding of mental disorders and revealed opportunities for change that would have remained hidden through a diagnosis-oriented perspective.

|11|Part ITheoretical Foundations

|13|1  Limitations of Diagnosis-Oriented Psychotherapy

1.1  Inadequate Conceptualization of Mental Disorders

Why bother with mental processes? Is it not enough to know the diagnosis and select the right evidence-based therapy? It works in somatic medicine, does it not? With the establishment of psychotherapy in health care, paradigms of somatic medicine have been applied to conceptualize mental problems. According to the latent disease concept of somatic medicine, it should be possible to identify diseases based on symptoms that differ in etiology, course, and responsiveness to treatments. This model promises to greatly simplify therapy and allow therapists to provide effective treatment even without an individualized understanding of the individual processes involved. Similar to the approach in somatic medicine, a prescribed treatment is derived from the diagnosis. This is almost standardized for all clients. The goal of this approach is that treatments can be offered in a disorder-specific, manualized, evidence-based, and guideline-driven manner. The associated hope is to treat according to a prescribed set of measures for each definable mental illness, thereby simplifying and improving treatment (Hofmann et al., 2016). As a result of this development, the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) now lists approximately 350 disorders for which more than 270 treatment manuals exist, and their efficacy is more or less well supported by outcome studies (Hofmann & Hayes, 2018). In many studies, the effectiveness and superiority of cognitive behavioral therapy (CBT) approaches over other methods could thus be demonstrated (Heidenreich & Michalak, 2013).

In the textbook or in the guidelines, this makes psychotherapy sound simple, almost like a cookbook. Depression can be determined by asking about nine symptoms using a checklist. If at least five of the nine symptoms are reported, the client can receive the diagnosis. But does this represent the psychotherapeutic reality? Are mental disorders so easy to categorize? Does it really make sense to define an arbitrary combination of five of the nine possible symptoms as depression? Why aren’t psychotherapies more effective if the psychotherapists treating them only have to reach for the right manual? The psychotherapeutic reality is actually more complex, dynamic, and individualized than the DSM and ICD (International Statistical Classification of Diseases and Related Health Problems of the World Health Organization, WHO) classification systems and the guidelines derived from them suggest (Deacon, 2013; Hayes, Hofmann, & Ciarrochi, 2020; Hofmann et al., 2016; McNally, 2016; Nelson et al., 2017). Neglecting this complexity and dynamic leads to limiting treatment outcomes on a practical level, which alienates psy|14|chotherapists and clients alike. Moreover, ignoring complexity and dynamics on a theoretical level hinders the advancement of psychotherapy because existing model conceptions that are disconnected from reality treads on the spot, instead of creating more refined models (Hofmann & Hayes, 2018; McHugh et al., 2009).

For the practitioner, the question also arises to what extent it is useful to know the more than 270 treatment manuals for the more than 350 DSM-5 categories if in individual cases it is unclear which comorbid disorder should be treated in which order with which therapy components. Especially in the outclient setting, the flood of disorder-specific approaches can overwhelm therapists and lead to the unsystematic application of different therapy components (Harvey et al., 2009). As a solution many therapists resort to a one size fits all approach, in which one treatment method is applied to all clients. Instead of using the evidence-based procedure designed for a specific disorder, a preferred method of treatment is used (Harvey et al., 2009). This is reflected in statements such as “I normally work according to acceptance and commitment therapy (ACT), which seems to suit me” or “I work eclectically, based on my personal opinion.”

The limitations of the current heterogeneous and overlapping diagnostic groups derived from the assessment of subjective client data have also been recognized by the American National Institute for Mental Health (NIMH). It initiated a comprehensive, multidisciplinary project over ten years ago to identify diagnostic groups based on measurable biological and behavioral process dimensions. Known as the Research Domain Criteria (RDoC) initiative, this project aims to diagnose mental disorders using clinical neuroscience methods rather than subjective symptom descriptions. This will involve, for example, electrophysiological and imaging techniques that map neurological structures or functions, genetic analyses, and standardized tests to study learning processes under laboratory conditions. As a result, mental disorders should be traced to core biological and behavioral dimensions (Insel et al., 2010). The dimensional nature would solve the problem of cut-off boundaries and better map the fluid transitions between mental health and mental illness. The hope is that valid structural or functional disease entities can be found at this biological level of analysis to replace the current categories. Although the project does not yet have direct consequences for changes to the existing DSM categories, it demonstrates that a paradigm shift should occur and that future models of mental disorders must be conceptualized dimensionally at a process level rather than categorically at a symptom level (Hofmann & Hayes, 2018) so that further development of concepts of mental disorders and their treatments is not hindered (Hayes, Hofmann, & Ciarrochi, 2020).

1.2  Complexity and Dynamics of Mental Disorders

In my practical work (M. S.), in the context of a psychosomatic clinic, singular disorders, as presented in most textbooks, are not only the exception, but virtually nonexistent. The results of the National Comorbidity Survey (Kessler et al., 1994), in which more than 65,000 persons were examined, showed that almost 80 % of the diagnoses were already comorbid disorders; in the case of severe mental illnesses, three or more other disorders were present in 89 % of the cases. The complexity and possible combinations of symp|15|toms in two to three disorders are so great that the supposed simplification provided by a diagnosis-oriented approach is lost. The currently dominant disorder-specific approaches are therefore only suitable for a few exceptional cases.

The results of comorbidity studies also support the low discriminant validity of diagnostic categories (Brown & Barlow, 1992) and that individual disorder components interact with each other at a transdiagnostic level (Harvey et al., 2009). Furthermore, what we see phenotypically at the symptom or diagnostic level has no clear correspondence at the process level. On the one hand, the same processes can be responsible for the development and maintenance of different mental disorders (Fisher et al., 2018; Harvey et al., 2009): A rumination process can maintain a depression, a generalized anxiety disorder, or a somatoform disorder. On the other hand, very many different processes can result in the same diagnostic category (Harvey et al., 2009): The core process behind depression can be a negative self-schema, but it can also be difficulties regulating negative affect, behavioral deficits, or relationship difficulties. The possible combinations of multidimensional, transdiagnostic processes are enormous. This possibility for variation explains, first, the great interindividuality of mental disorders and, second, the great variation in mental health complaints across the life span (Harvey et al., 2009). The assumption that common core processes are responsible for the development and maintenance of different disorders also explains why recorded comorbid mental disorders improve in treatment studies, even if they are not specifically treated (Borkovec et al., 1995; Brown & Barlow, 1992; see also Harvey et al., 2009).

These findings indicate that isolated illnesses as classified in the DSM or ICD are rare, and thus attention should be focused on core transdiagnostic processes of psychopathology and psychotherapy (Hayes, Hofmann, & Ciarrochi, 2020; Hofmann & Hayes, 2018).

1.3  Somatic or Latent Disease Model

Transferring the diagnosis-oriented approach of somatic medicine to mental illness only makes sense if the individual symptoms are produced – independently of one another – by an underlying disease entity (see left side of Figure 1). For example, a lung tumor produces the symptoms of cough, chest pain, and breathing difficulties. If the disease disappears, the symptoms caused by the disease disappear. This model, which assumes existing disease entities, has been applied to mental illness, although the individual symptoms are usually not independent of each other (“axiom of local independence”) and symptoms can persist even if the disease disappears (Hofmann et al., 2016).

The right side of Figure 1, on the other hand, depicts a disease model based on a network understanding: Here, the individual symptoms of disorders interact highly with each other and contribute to overlapping diagnostic categories. The mental disorder is the network of interacting symptoms and processes (e.g., rumination process, avoidance behavior, emotional states). The symptoms and the interactions between these processes are already the pathology to be treated and do not indicate an underlying disease, as assumed in the “latent disease” model of somatic medicine (left side of Figure 1) (Hofmann et al., 2016). According to the network model, mental disorders can be viewed as a dynamic network or complex system. The elements of this psychopathological system are interact|16|ing processes at the cognitive, emotional, somatic, and behavioral levels. Because of these multidimensional interactions, the psychopathological system, similar to other complex systems (e.g., the weather), cannot be described with linear or causal models. It is dynamic and nonlinear and thus requires a different approach.

Figure 1.  Somatic disease model (left) vs. complex network understanding (right). The symbols in the middle represent different symptoms.

1.4  Applying Linear Thinking to Complex Systems

In everyday life, a relatively linear and causal way of thinking is usually sufficient. I am out of coffee, so I have to buy coffee. If I am hungry, I eat something. If I have a psychological problem, I think about solutions. And that’s where it starts to get complex. Thinking can contribute to the solution. But the thoughts can also branch out and reinforce the problem or even create new problems. The pondering can make you feel helpless, and the helplessness can trigger a chain of other feelings, such as inferiority and guilt. As a result of my ruminating, behaviors or relationships may change. The psyche consists of numerous subsystems that are highly interconnected. Such complex systems cannot be represented with linear cause–effect notions. They behave dynamically and nonlinearly.

Understanding complex systems such as mental disorders requires a systemic perspective (McKey, 2019; Meadows, 2008). A system can be described simplistically using three components: It consists of (1) elements (what is seen), (2) connections or relationships among these elements, and (3) a function or purpose of the system. The latter can be seen in the effects (see Figure 2).

The system “soccer game” for example has the elements player, ball, goal, and field. The relationships are the actions in the game that occur between the elements and the applied rules affecting the game. The purpose or function is to get the ball into the opponent’s goal and at the same time prevent the ball from entering your own goal while adhering to the rules. What is the most important thing if you want to define or understand the system behind a soccer game? If you change the elements (players), it is still a soccer game. However, if you change the relationship patterns, for example, by having oppos|17|ing players pass the ball to each other, the system changes. The impact on the system becomes even stronger if you change the function or purpose. If the purpose is not to touch the ball (avoidance), the system “soccer game” collapses. Although the elements (players) seem to play an important role, the interactions on the process level and the function of the system are by far more important from a systems perspective. In addition, this example is a good illustration of the effects of a system focused on avoidance: Such a soccer game would quickly become unbearable for both players and spectators.

Figure 2.  Psychopathology from a systemic perspective.

This picture can be transferred to the diagnosis-oriented view of mental disorders, which focuses on the visible symptoms (elements) or the content: We mistake the elements (visible symptoms) for being the decisive thing, but this does not really help us understand the dynamics of the psychopathology involved in mental disorders. It is not the symptom itself – such as negative thinking – that defines psychopathology, but how negative thinking affects mood, behavior, or relationships and how interactions between elements create patterns that cause the individual to suffer. So, the interactions are more important than the elements. Even more defining for a system is the function or purpose. If the elements and the interaction between elements is to “avoid uncertainty,” the system will develop into a different state than if the function or purpose is to “grow and learn.” Similar to a sports game, the interactions between the elements (processes) and the function (purpose) are the essential thing to understand the complex system of a mental disorder. Consequently, if we want to change the “mental game” through therapy, we have to influence the game processes and the game purpose – not the elements. That means not changing the thoughts and emotions, but changing the way a person relates to these elements.

This is important in that it is usually the elements of the system that are visible, but the processes can only be experienced through the effects and by recognizing patterns (McKey, 2019). Symptoms are not in general a problem. We all have negative thoughts, we ruminate, have mood dips, or feel inadequate. Only when these symptoms start to in|18|teract with each other and cause dynamics that lead to enduring suffering do they become relevant in a clinical sense. But still, it is the dynamic interactions of the processes causing the problems – not the symptoms.

1.5  Heterogeneity of Diagnoses

As clinicians, we have become accustomed to the fact that the diagnosis says little about the reality of the disorder. Two different people diagnosed with major depression may have completely different clinical pictures: One may be completely incapacitated and suicidal and therefore need to be placed in a closed psychiatric ward, while the other may visit a psychotherapeutic practice after work with a relatively inconspicuous outward appearance. At the symptom level, myriad combinations are possible, so that two people with major depression according to DSM-5 may share only one symptom out of a possible nine. Fried and Nesse (2015) were able to show that if all the subsymptoms of depression are included, 16,400 different symptom profiles are possible. There are 280 depression questionnaires with a variety of different symptoms. The seven most common methods use 52 symptoms, whereas the DSM-5 system uses only nine symptoms (Dalgleish et al., 2020; Fried, 2015). Even when diagnoses remain the same, there is high phenotypic plasticity between diagnostic categories across the life span.

Sticking to the analogy of a soccer game: The categorial diagnosis of a mental disorder is about as informative as a photo of a soccer match (see Figure 3). At this level of observation, one sees what is being played, but not how it is being played. The dynamics and complexity of the (game) process are not captured. Moreover, the temporal dimension is not captured by this static snapshot. Looking at the progression of the disorder over time, one perceives how individual aspects of the disorder influence each other. For example, withdrawal behavior can lead to more brooding, and this in turn can increase withdrawal. It is not the individual symptoms that are the problem but the way they reinforce each other and make the sufferer feel helpless. By looking at changes over time, one can infer cause–effect relationships and form hypotheses about processes operating in the background (Gloster & Karekla, 2020).

In a soccer game, a trainer needs to watch a game evolve to see which tactics lead to success and which jeopardize it. On this basis, considerations can be made as to how a team can improve its game: What game processes would have to change in order for the style of play to change? What should the team train on to be more successful? Improving the game and developing competencies of a specific team to become more successful is not possible on the basis of the static information of a snapshot. To make improvements, the coach needs to observe the variations of the game processes, to gain an understanding of the dynamics and functioning of the game. Applied to psychopathology, this means that a snapshot of symptoms is not sufficient to understand the dynamics of the disorder. Only when I understand how cognitive, emotional, and behavioral processes play together to repeatedly create a net of depressive symptoms can I understand and individually address the maintaining conditions of the depressive network.

|19|1.6  Nomothetic Versus Ideographic Explanatory Models

The oversimplifying diagnostic categories of DSM are not only a problem for therapists. Clients, too, often do not recognize themselves in the diagnoses. Sometimes this is experienced as a tug-of-war in which the therapist focuses on disorder-specific factors, whereas for the client, an individual conditioning factor plays a far greater role in causing distress. Although a diagnosis-oriented and manualized approach has set treatment standards and facilitated basic modeling of individual mental disorders (Clark et al., 1997), the emphasis on diagnosis has obscured the view of individual processes relevant to the disorder as well as individual and contextual factors (Hayes, Hofmann, & Ciarrochi, 2020; Hofmann & Hayes, 2018).

Figure 3.  The diagnosis of a mental disorder can be compared to a snapshot of a soccer match. It does not allow any statement about which processes determine the game. The dynamics of the game and how well a team is performing are hidden when you are not able to analyze the interacting processes over time (© iStock.com/simonkr).

The problem arises, among other things, from the fact that clinical research derives most of its knowledge from studying groups and comparing people with and without a diagnosis. It examines how variables differ at a group level, rather than how they behave at an individual level. If it is found that depressed people have lower activity levels compared to nondepressed people, it is reasonable to conclude that depressed people should be activated. On average, this statement is true for the group as a whole, but it is not applicable to a specific person in a specific situation (Hofmann et al., 2016). What is true for the group is far from true for each individual group member. Often, individual group members deviate greatly from the group average. The average shoe size is relatively uninteresting when you want to buy shoes: You do not buy a size that would fit a statistically determined average person, but shoes that fit you.

|20|In contrast to nomothetic models, which look for general regularities, ideographic models try to explain the individual and particular in each case. Steven Hayes illustrates the difference between ideographic process research and nomothetic research in his lectures with a simple example. When examining typing proficiency at the group level, people who can type very quickly will be proficient and therefore make fewer errors. In contrast, when examined at the individual level, higher typing speed leads to more errors. Both research methods examine the relationship between typing speed and error frequency. However, the results of the two research methods are opposite. It would therefore be wrong to transfer the results of the group study to the individual level and recommend to beginners in a typing course: “Research has shown that people who type quickly make fewer errors. Therefore, type as fast as you can.” However, this is exactly the mistake we make when we transfer the results from nomothetic research to individuals (Hofmann, Curtiss & Hayes, 2020).

Ideographic process knowledge is the core of process-based psychotherapy. In ideographic process research, one looks at how variables change in an individual person and how these variables interact with other variables over time at the individual level. This individualized conception also explains how the same processes can result in different disorder categories (Fisher et al., 2018). In one case, worry and thought loops can lead to the development of generalized anxiety disorder. In another case, this derailed cognitive process combined with low self-esteem can promote depression. In a third case, together with increased self-attention to physical symptoms, it may condition a somatoform disorder. However, an exaggerated rumination process can also remain without major consequences. One client who worried constantly reported that this was her way of being close to other people. Worrying, she said, meant that she was well and felt connected to other people. She did not find worrying stressful. In fact, for her, the worrying process had positive effects because it kept her in contact through her caring motive.

These remarks illustrate that the diagnosis-oriented approach primarily considers factors that are supraindividual or represent general effects. The process-based approach, on the other hand, is interested in ideographic processes that are responsible for the emergence and maintenance of psychological distress in a particular person, in a particular context, at a particular time (Hofmann & Hayes, 2018).