Profile: Professor Stefan Hofmann Discusses Process-Based CBT

Professor Stefan Hofmann is an influential clinical psychologist, researcher and expert in anxiety disorders and CBT. He is the Alexander von Humboldt Professor at the University of Marburg, Professor of Psychology at Boston University, and Editor-in-Chief of the journal Cognitive Therapy and Research. He has also developed Process-Based Therapy in collaboration with Steven Hayes.

Psychology Tools were incredibly lucky to have some time talking to Stefan. We discussed why now is the right time for a process-based approach, rethinking psychology, treating mental health problems like broken arms and striving to know what you don’t know.

A different way of conceptualizing mental health problems

What is Process-Based Therapy and why should therapists be using this approach?
Firstly, I’d say process-based therapy is not a new form of therapy. It is a different approach for dealing with mental health problems. In psychiatry and clinical psychology, I think over the years we have been too focused on syndromes and diagnoses, and the idea that they are somehow latent diseases behind surface symptoms such as depression, anxiety disorders or even schizophrenia. People have been trying for decades to analyze these syndromes in the hope that we would eventually hit the jackpot and understand the genetic basis of depression or a biomarker of anxiety, whatever that might be.

That turns out to be a wrong approach. When it comes to clinical practice, clinicians very often step outside of these very narrow ways of dealing with mental health problems. A good clinician tries to understand the person, in all their complexity; not only the so-called symptoms as they present themselves, but also the social and cultural context the person is embedded in, as it all matters. So seeing the client in their entirety and not as a compilation of DSM or ICD syndromes is our starting point. We are building a science based on clinical experience, and that leads very naturally to process based therapy.

It is not necessary to assume that latent diseases exist in order to treat a person appropriately. We want to understand not only that a person has certain problems but also how these problems hang together. For a very simplistic example, sleep problems might be directly linked to attention problems, which might be related to a negative self-view, and there may also be certain social issues happening for this person as well. These things hang together in a complex way. Not everything hangs together, but certain problems do very closely. Some of these problems form very central challenges, while others are not as central. For some people, sleep might be a very critical point, but for others the critical problem will be something else.

The point here is that good clinicians are trying to understand what is most relevant for the particular individual sitting in front of them. We are moving away from a nomothetic grouping; putting everybody together in one group, for example the category of ‘depression’, and saying that they all look roughly alike. Currently, people labeled with the term ‘depression’ all get the same treatment, maybe an anti-depressant medication. Unfortunately, we’ve even been moving in this direction in psychotherapy. We have manuals that target syndromes, and while there is some room to maneuver, that is, in essence, how we treat depression, or panic disorder. We are also moving into this cookie cutter approach online. But instead of treating a disease, we should be treating a person who experiences problems. 

Complex networks and processes
With process-based therapy we’re stepping away from this, and moving to a very strongly ideographic approach, where we try to understand the complexity of the individual. This gets us to something called dynamic networks. The way a person is, in essence, forms a complex network. Mental health problems form complex networks, whether they are cognitive, behavioral, social, or cultural issues. Once we understand this network, we can not only have a better understanding of the person’s idiosyncratic problems, but it allows us to intervene much more effectively in a way that disturbs the maladaptive networks.

Therapy, in a way, is a process – and I’m emphasizing the word process – that changes a maladaptive network into an adaptive one. We aren’t just trying to understand what the maladaptive processes are that maintain the problem – there are many things to consider. In clinical practice, we also need to identify adaptive processes that compete with these maladaptive processes, and introduce nodes in the network that turn a maladaptive network into adaptive one. We also need to identify what maintains an adaptive network, so people don’t switch back into old patterns of thinking and maladaptive ways of dealing with things. It’s a dynamic process.

The essence of process-based therapy is to identify the processes that are involved in turning these networks from maladaptive to adaptive. We’re not introducing new techniques or other therapeutic strategies. Exposure to anxiety, behavioral activation and cognitive restructuring for depression are all strategies that are still in our clinical toolbox. In fact, the toolbox that clinicians have available is a fairly limited set of strategies, but the art of therapy is to put these strategies into use in the most effective way, for each individual client, in each individual situation. So, for this reason, we want to step away from a ‘protocols for syndromes’ approach, where we treat a label, and we move toward an idiographic approach where we treat the individual.

What do you think is most helpful about process-based therapy from a clinical perspective, for therapists using this approach?
I think one helpful and important thing is for clinicians to step away from their own theoretical orientation. CBT therapists focus very much on cognitions and behaviors, whereas psychodynamically oriented therapists will focus very much on relationship issues and self-related issues, and a third wave CBT therapist will probably focus on values. There are differences in approaches, and there’s nothing wrong with that. The person’s problem network is the way it is, and if we can find different entry points to disrupt the system, that’s fine, but we also need to widen our lens as clinicians and step away from our own theoretical orientation. CBT therapists should not only focus on cognitions and behavior, but also examine past and current relationship issues, and psychodynamic therapists shouldn’t only focus on these issues and ignore cognitions and behaviors, etc. Most clinicians, and even most of my colleagues, would say “That’s what I do. I always focus on the entirety of the person”, but clients still need to shop around to find the right therapist who seems to understand their problem.

When you have a broken arm, you don’t have to shop around for the right person to put your arm in a cast. It’s very simplistic, obviously, but we know what to do with a broken arm. If you go to a healer who gives you herbal tea to fix your arm, you are being maltreated: it’s that simple. This is unfortunately what people struggling with mental health issues sometimes face. There are fairly simple ways to help a person, the challenge is to understand what the problem is, and then to choose the right strategies to apply to a given problem. Process based therapy guides clinicians, regardless of their theoretical orientation, toward the right path – towards knowing the arm needs to be in a cast to get fixed.

Why do you think we went so far down the nomothetic path?
There are good reasons why we are in the situation that we are, and it’s important to know some of the history to understand our current situation. I trained as a cognitive behavioral therapist with Dr. Beck, who unfortunately just passed away in November 2021 at the age of 100. We’ve made tremendous progress in treating mental health issues using cognitive behavioral principles. In fact, CBT was initially a sort of stepchild of mental health delivery. People thought that if certain drugs didn’t work, the second option was to try a short-term therapy called CBT, which seemed to work well for some people. It turned out that it wasn’t only a viable alternative, but also in most cases, a first line treatment. As you see now in the UK with the IAPT programme, it has revolutionized the field.

We got sucked into this simplistic, reductionistic way of seeing mental health by putting people in these categories of nosology. We assign them a label, and you get a particular CBT approach via that label, but CBT actually started out as a very broad, nonspecific intervention. When I was trained with Dr. Beck, there was just one CBT. You adjusted it to the client, but you didn’t have CBT protocols. At that time, the hope was that we would develop different drugs for all these different DSM labels. That’s why the DSM and the ICD are so successful, and why the pharma industry wants them to exist – because they can sell a lot of drugs. It turned out that the situation flipped. Now we have a few drugs that we apply to every label – the SSRIs that seem to be the aspirin of psychiatry. You have a problem, you take SSRI whether it may be for mood, anxiety problems, or premenstrual syndrome. Even premenstrual syndrome became a DSM label.

I was an advisor to the DSM 5 development process, and it became clear how arbitrary a process it was, albeit a hard-working one. There was nothing that guided us, as to why the diagnosis criteria should be 6 and not 5 of the 12 symptoms, for example. So, the situation flipped and we had one drug, or a few drugs that you now apply to everything and CBT became overly specific. We have CBT for this and CBT for that, who can possibly learn all of these different treatment protocols? In clinical practice, it just isn’t useful anymore, so a new era needs to start. It’s not to say that CBT was, or is useless. It certainly isn’t. CBT has made enormous progress, but now we need to think about the way we’ve been, and still are, using it to treat mental health.

Putting it into practice

How do experienced therapists respond when they start learning about applying and integrating PBT into their practice? What advice do you give for anyone thinking about using the approach?

We offer PBT workshops, and we recently published a book called ‘Learning process-based therapy’. When we do these workshops, the most experienced therapists often tell us that they’ve been doing something similar to this approach all along, but they find the process-based approach useful because it guides them in a more systematic way.

So how do you actually do it? You ask open ended questions, the right questions to help the therapist establish the network for the client. You are trying to stay within a framework. The theory provides a broad framework which gently guides people through a step-by-step process. It’s not anything goes at all, but it provides broad guidelines about how to go about this kind of intervention. We make it very clear these are existing, established strategies, not new ones that we have introduced. The difference is that we combine them in a way that best fits the individual. It is a new way of conceptualizing mental health problems, and it’s also a new way of doing clinical science.

Average is an imaginary construct
Focusing on the individual is a radical departure from what we’ve been doing. We are trained in a nomothetic world, and have been trained to think in terms of averages and standard deviations. Statistics is our methodological bread and butter, but in clinical practice, we don’t really care about the average, we care about the individual and the differences between individuals.

That’s not to say that there are as many worlds as there are individuals. We hope to group people who share similar networks more meaningfully together. What they are labeled as is irrelevant, but they might belong more together, because certain problems have similarities. We need to start from the ground up and let the clinical data and experience guide us rather than moving from top down and assuming very simplistic ideas about human functioning and mental health.

We have high ambitions: to rethink psychology at its core. Because the nomothetic approach led us in a wrong direction for too long, we can’t understand individual differences if we look at normative data. The nomothetic approach has a role if we want to understand groups, but if we want to understand the individual, we need to use individuals as our research subjects, and approach it in a different. The average person, after all, doesn’t exist, they are an imaginary thing, a statistical dream.

Philosophical differences and shaping process-based thinking

Your background has been CBT focused and disorder specific. You’ve talked about your friendship with Steve Hayes and your philosophical differences. How did those differences help to shape the process-based approach?

Steve came from an ACT [Acceptance and Commitment Therapy] perspective, and our strong philosophical differences have been around the issue of cognitions in particular. I think we still have them: he’s more of a constructivist, whereas I’m more of a realist. There are things out there in nature that we need to understand, that exist without us looking at them, or without us having theories about them. Steve does not think that’s the case. The term cognition is a very hotly debated issue, and obviously, as a cognitive behavioral therapist I have strong opinions about what cognition is, and Steve does!

We’d been struggling around this issue, but then we found common ground. We are both really interested in understanding why things change, and why people change. How to move them towards change and how we can facilitate the adaptive process.

Learning from evolutionary science
Steve brought in a very interesting concept that I’d never tied to the idea of change before, so this is definitely his influence. The concept is how evolutionary science can actually inform the change process. Evolutionary science isn’t just focused on developing how we understand species, and natural selection. Evolutionary science also gives us a framework in understanding adaptiveness in every individual. Context determines adaptability, so something can be adaptive in one context, and very maladaptive in another context. Cultural phenomena are obvious examples of this, but even within the same culture it sometimes depends on the context whether something is adaptive or not. In evolutionary science, when something becomes maladaptive, there are problems in variation, selection and retention in a given context. If you don’t show variation, eventually you’ll hit maladaptation. Context will always change – it’s just a matter of time because life is an evolving process. There’s nothing that stays constant in this expanding and changing universe, so everything within it is also changing. If you choose something, there might be healthy variation, but you might select something that isn’t adaptive, and that problematic selection also leads to maladaptation. Finally, if you have shown healthy variation and healthy selection, but then don’t retain what seems to have worked in a given context, this also results in maladaptation.

These broadly defined over-arching processes; variation, selection, and retention in a given context, are the broad framework of process-based therapy. We call this framework an ‘extended evolutionary metamodel’ and it provides us with a framework that is broad enough to accommodate any theoretical orientation, whether it be psychodynamic, CBT oriented, or something else. In any therapy, you should always introduce healthy variation, selection and retention for the given context in some way.

You!

We’re really interested in the person behind the theories, as well as the thinking itself. As a hugely accomplished academic, are there still areas you feel unsure of or find nerve wracking in your professional life?
It’s impossible to know everything, so I think you have to feel comfortable with the fact that you don’t, and you have to be honest about it. My goal has always been to know just enough to know what I don’t know. I don’t want to be an expert in all things, but rather to have a rough idea of what something potentially involves (i.e., some complex statistical modeling dynamic network stuff), even if that means going outside my area of knowledge. You can get easily into a situation where you say ‘this is way too big for me’ and step away from it, but there are obviously many people who have the right expertise, and I want to work with those people. I’m not an expert in everything, but I work with experts in these fields and try to move into the right direction. I think I know what I don’t know.

How did you feel as a clinician – did you enjoy that element of your work?
Clinical work has always been part of my life. I don’t have much time for direct patient interaction anymore, but through supervision I can guide other therapists to work with the clients I’ve had. Since I moved back to Germany, I discontinued my last case, but I’ve had patients all throughout my career, and I might also pick up some cases here now. Anybody who’s worked in clinical science needs to stay in touch with clinical practice.

Finally, tell us a little bit about your time working with Anke Ehlers and David Barlow. How did they influence you?
In more ways than I can tell. I was Anke’s first doctoral student, when she came to Marburg from Stanford, so she’s been incredibly inspirational. She is an absolute role model when it comes to her way of dealing with extremely complex issues. She is a very generous and brilliant woman. It’s not easy for women to succeed in academia, but at that time it was even harder. She was masterful in her role, and never engaged in the power struggles; she stepped away from them instead. She convinced people with her brilliance. I’m very proud to be her mentee.

Dave Barlow is just a giant in the field, and just as inspirational. A very broad and deep thinker, his breadth is incredible. He has also a real instinct for where the field is going in a way that I haven’t seen in anybody else. I’m very fortunate to continue working with him. He’s retired now but I work with him on Abnormal Psychology, a popular textbook which we renamed into Psychopathology recently. The details in each segment give you a glimpse into his breadth – it’s a massive undertaking. I’ve learnt a lot working with him.

	Hofmann, S. G., Hayes, S. C., Lorscheid, D. N. (2021). Learning Process-Based Therapy: A Skills Training Manual for Targeting the Core Processes of Psychological Change in Clinical Practice. New Harbinger.
	Hayes, S. C., Hofmann, S. G. (2018). Process-Based CBT: The science and core clinical competencies of cognitive behavioral therapy. New Harbinger.
	Hayes, S. C., Hofmann, S. G., & Ciarrochi, J. (2020). A process-based approach to psychological diagnosis and treatment: The conceptual and treatment utility of an extended evolutionary meta model. Clinical Psychology Review, 101908.
	Hofmann, S. G., Sawyer, A. T., Fang, A., & Asnaani, A. (2012). Emotion dysregulation model of mood and anxiety disorders. Depression and Anxiety, 29(5), 409-416.
	Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(5), 427-440.