There is a coming revolution in psychotherapy, counselling, and clinical psychology, and I believe this book, Learning process-based therapy: A skills training manual for targeting the core processes of psychological change in clinical practice (Hofmann et al., 2021) is at the forefront. To understand what this book offers, we must first understand the dramatic changes occurring in the field today. Researchers have spent decades evaluating evidence-based protocols to treat “psychological diseases”. This might be called a “protocol-for-syndrome approach” and has resulted in much good work which has been effective, but the effect sizes in clinical psychology have stagnated for the last 30 or 40 years. We need a fresh approach. A stalemate often results from research that pits one active package (say, schema therapy) against another (say, cognitive behavioural therapy). It is difficult to demonstrate that one package is superior to another across all contexts and people, simply because evidence-based packages are not a single “thing” but rather a collection of evidence-based processes, many of which are shared across packages.
This has led to a call to focus on evidence-based processes instead of packages (Hayes et al., 2020). Focusing on processes allows one to pick what is most useful for a particular client, which naturally leads to personalisation of the intervention. There is no one size fits all. Not everybody needs to be taught to practise structured mindfulness or cognitive reappraisal. If something is not working, we do not need to stick relentlessly to the evidence-based protocol. We can focus flexibly on the processes most needed by the client.
Learning process-based therapy (Hofmann et al., 2021) will become known as a classic, early expression of these bold ideas. Written by the founders of this approach, the book provides a practical guide to process-based therapy (PBT). The first chapter walks the interested reader through many of the issues raised above concerning the inadequacy of continuing the same protocols-for-syndromes approach.
In chapters 2 and 3, the authors introduce the practitioner to radically new ways of thinking about clinical problems. The strength of these chapters is that they do not advocate for a particular type of therapy. One could be a cognitive behavioural therapist, a schema therapist, or an acceptance and commitment therapist, or belong to any of the many schools of clinical psychology, and still engage with the book and transform one’s practice into a more process-based approach.
It is worth taking a moment to pause and consider the implications of this idea. This approach to PBT does not require practitioners to forgo their evidence-based approach. The book presents PBT as a “meta” approach rather than an approach that competes with particular therapies. The book helps practitioners to express and transform that approach in a way that facilitates personalised intervention according to the clients’ needs. Using this approach, practitioners can also integrate technologies from different approaches in a coherent, theoretical way. Chapters 2 and 3 demonstrate how to do that.
Looking across different therapies, we might identify a bewildering number of processes and approaches. However, chapters 4 and 5 introduce a practical framework to organise these different processes. The chapters provide examples and descriptions of six different process dimensions, namely, cognition (e.g., reappraisal), affect (e.g., emotional acceptance), attention (e.g., present moment awareness), self (e.g., self-efficacy), motivation (e.g., value clarification), and overt behaviour (e.g., goal setting). The book also provides plenty of concrete clinical examples and case studies. For instance, chapter 6 demonstrates how to expand interventions to different levels, including biological, individual, and social levels. This combats our natural tendency to stick to the level we are most comfortable with. Throughout chapter 7, the practitioner learns how to help clients become sensitive and adaptive in their own context and retain what they learn in therapy.
During the middle chapters, not only do we learn fresh approaches to intervention, but also we conduct a comprehensive review of the interventions we commonly use and the interventions and dimensions that we underemphasise. As practitioners, we all have our favourite interventions, and it is natural to emphasise those interventions and potentially neglect others. Learning process-based therapy (Hofmann et al., 2021) allows us to take a comprehensive look at our practice. The book provides many useful tables and worksheets that help practitioners to survey their usual practices and develop new practices that are likely to improve the efficacy of their interventions.
In chapters 8 and 9, the practitioner learns how to use a network-based and system-based approach to implement PBT. This approach emphasises the possibility of very slow change followed by sudden, rapid change. The system-based perspective helps explain clinicians’ frequent experience that client improvement is rarely continuous: there might be a long period of slow improvement, or even none, and then suddenly the client’s entire life changes for the better.
A huge strength of PBT is the ability to integrate interventions from different therapeutic “islands”. Chapter 12 gives the practitioner the skill to do this by helping us to think in terms of treatment kernels, the essential component of a psychological treatment. Once we develop the skill of identifying kernels, we are empowered to learn widely different evidence-based therapies and make sense of how we might use elements of them in our own practice. How many of us have experienced sitting inside a workshop, learning an exciting new approach, but saying to ourselves, “How do I integrate this into what I already do?” This chapter, and indeed this entire book, helps answer that question.
The practitioner will learn a considerable amount from this book. It contains many practitioner tools, it is easy to read, and it is well organised so that it may be kept in the therapy room for reference. I would recommend this book as an essential read for practitioners interested in moving towards process-based and personalised forms of intervention.