Process-Based CBT Cap.1

PROCESS-
BASED
CBT
The Science and Core Clinical
Competencies of Cognitive
Behavioral Therapy
Edited by
STEVEN C. HAYES, PhD
STEFAN G. HOFMANN, PhD
Context Press
An Imprint of New Harbinger Publications, Inc.
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Copyright © 2018 by Steven C. Hayes and Stefan G. Hofmann

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Figure 1 in chapter 11 is reprinted from Cahill, K., Hartmann-Boyce, J., & Perera, R. (2015).
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Contents
Introduction�� 1
Steven C. Hayes, PhD, Department of Psychology, University of Nevada, Reno;
Stefan G. Hofmann, PhD, Department of Psychological and Brain Sciences,
Boston University
Part 1
1 The History and Current Status of CBT as an

Evidence-Based Therapy �� 7
Boston University; Steven C. Hayes, PhD, Department of Psychology, University
of Nevada, Reno
2 The Philosophy of Science As It Applies to Clinical Psychology�� 23

Sean Hughes, PhD, Department of Experimental Clinical and Health Psychology,
Ghent University
3 Science in Practice�� 45
Kelly Koerner, PhD, Evidence-Based Practice Institute
4 Information Technology and the Changing Role of Practice�� 67

Gerhard Andersson, PhD, Department of Behavioral Sciences and Learning,
Linköping University, and Karolinska Institute
5 Ethical Competence in Behavioral and Cognitive Therapies�� 83

Kenneth S. Pope, PhD, Independent Practice, Norwalk, CT
Part 2
6 Core Behavioral Processes�� 101

Mark R. Dixon, PhD, and Ruth Anne Rehfeldt, PhD, Rehabilitation Institute,
Southern Illinois University
Process-Based CBT
7 What Is Cognition? A Functional-Cognitive Perspective�� 119

Jan De Houwer, PhD, Dermot Barnes-Holmes, DPhil, and Yvonne Barnes-
Holmes, PhD; Department of Experimental Clinical and Health Psychology,
Ghent University
8 Emotions and Emotion Regulation�� 137

Anthony Papa, PhD, and Emerson M. Epstein, MA; Clinical Psychology PhD
Program, University of Nevada, Reno
9 Neuroscience Relevant to Core Processes in Psychotherapy�� 153

Greg J. Siegle, PhD, Western Psychiatric Institute and Clinic, University of
Pittsburgh, Pittsburgh; James Coan, PhD, University of Virginia
10 Evolutionary Principles for Applied Psychology��179

Steven C. Hayes, PhD, Department of Psychology, University of Nevada;
Jean-Louis Monestès, PhD, Department of Psychology, LIP/PC2S Lab, University
Grenoble Alpes; and David Sloan Wilson, PhD, Departments of Biology and
Anthropology, Binghamton University
Part 3
11 Contingency Management�� 197
Stephen T. Higgins, PhD, Vermont Center on Behavior and Health; Departments
of Psychiatry and Psychological Science, University of Vermont; Allison N. Kurti,
PhD, Vermont Center on Behavior and Health; Department of Psychiatry,
University of Vermont; and Diana R. Keith, PhD, Vermont Center on Behavior
and Health; Department of Psychiatry, University of Vermont
12 Stimulus Control��211
William J. McIlvane, PhD, University of Massachusetts Medical School
13 Shaping �� 223

Raymond G. Miltenberger, PhD, Bryon G. Miller, MS, Heather H. Zerger, MS,
and Marissa A. Novotny, MS, Department of Child and Family Studies,
University of South Florida
14 Self-Management�� 233
Edward P. Sarafino, PhD, Department of Psychology, College of New Jersey
iv
Contents
15 Arousal Reduction�� 245

Matthew McKay, PhD, The Wright Institute, Berkeley, CA
16 Coping and Emotion Regulation�� 261

Amelia Aldao, PhD, and Andre J. Plate, BS, Department of Psychology,
The Ohio State University
17 Problem Solving�� 273

Arthur M. Nezu, PhD, Christine Maguth Nezu, PhD, and Alexandra P.
Greenfield, MS, Department of Psychology, Drexel University
18 Exposure Strategies�� 285

Carolyn D. Davies, MA, and Michelle G. Craske, PhD, Department of
Psychology, University of California, Los Angeles
19 Behavioral Activation�� 299

Christopher R. Martell, PhD, ABPP, Department of Psychological and Brain
Sciences, University of Massachusetts, Amherst
20 Interpersonal Skills�� 309

Kim T. Mueser, PhD, Center for Psychiatric Rehabilitation and Departments
of Occupational Therapy, Psychology, and Psychiatry, Boston University
21 Cognitive Reappraisal�� 325

Amy Wenzel, PhD, ABPP, University of Pennsylvania School of Medicine
22 Modifying Core Beliefs�� 339

Arnoud Arntz, PhD, Department of Clinical Psychology, University of
Amsterdam; Department of Clinical Psychological Science, Maastricht University
23 Cognitive Defusion�� 351

J. T. Blackledge, PhD, Department of Psychology, Morehead State University
24 Cultivating Psychological Acceptance�� 363

John P. Forsyth, PhD, and Timothy R. Ritzert, MA, Department of Psychology,
University at Albany, State University of New York
v
Process-Based CBT
25 Values Choice and Clarification�� 375

Tobias Lundgren, PhD, and Andreas Larsson, PhD, Department of Clinical
Neuroscience, Center for Psychiatry Research, Karolinska Institute; Stockholm
Health Care Services
26 Mindfulness Practice �� 389

Ruth Baer, PhD, Department of Psychology, University of Kentucky
27 Enhancing Motivation �� 403

James MacKillop, PhD, Peter Boris Centre for Addictions Research, Department
of Psychiatry and Behavioural Neurosciences, McMaster University; Homewood
Research Institute, Homewood Health Centre; Lauren VanderBroek-Stice, MS,
Department of Psychology, University of Georgia; and Catharine Munn, MD,
MSc, Peter Boris Centre for Addictions Research, Department of Psychiatry and
Behavioural Neurosciences, McMaster University; Student Wellness Centre,
McMaster University
28 Crisis Management and Treating Suicidality from a

Behavioral Perspective �� 415
Katherine Anne Comtois, PhD, MPH, Department of Psychiatry and Behavioral
Sciences, University of Washington; and Sara J. Landes, PhD, Department of
Psychiatry, University of Arkansas for Medical Sciences, and Central Arkansas
Veterans Healthcare System
29 Future Directions in CBT and Evidence-Based Therapy�� 427

Steven C. Hayes, PhD, Department of Psychology, University of Nevada, Reno;
Boston University
Index �� 441
vi
Introduction
Steven C. Hayes, PhD

Department of Psychology, University of Nevada, Reno
Stefan G. Hofmann, PhD

Department of Psychological and Brain Sciences,
Boston University
The goal of this book is to present the core processes of cognitive behavioral
therapy (CBT) in a way that honors the behavioral, cognitive, and acceptance
and mindfulness wings of this family of approaches. The book is unique not just
in its breadth, but in its attempt to lay the foundation for real understanding and
common purpose among these wings and traditions.
So far as we are aware, this textbook is the first to be broadly based on the
new training standards for teaching the clinical competencies developed by the
Inter-Organizational Task Force on Cognitive and Behavioral Psychology Doctoral
Education (Klepac et al., 2012). What we will refer to here as the “training task
force,” organized under the auspices of the Association for Behavioral and
Cognitive Therapies (ABCT), brought together representatives from fourteen
organizations for four days of face-to-face meetings and several phone conferences
spread out over ten months in 2011 and 2012. The organizations ranged across
the wings and generations of thought in cognitive and behavioral practice, from
the Academy of Cognitive Therapy to the Association for Contextual Behavioral
Science, and from the International Society for the Improvement and Teaching of
Dialectical Behavior Therapy to the Association for Behavior Analysis
International.
This training task force was charged with developing guidelines for integrat-
ing doctoral education and training in cognitive and behavioral psychology in the
United States. The result was a thoughtful review of the contemporary literature
and concrete recommendations that serve as the basis for this book.
Process-Based CBT
No one book could cover all of the areas that the training standards do. We
decided to set aside training issues in research methods and assessment, since
they are so well covered in existing volumes, and instead focus on areas that seem
to us to involve new ideas and new sensitivities that are not well represented in
existing volumes.
In the area of scientific attitude, the task force training standards take two
strong stands: “The first proposition is that doctoral study in CBP [cognitive and
behavioral psychology] includes foundational work in the philosophy of science”
(Klepac et al. p. 691), and the “second proposition is that ethical decision making
is fundamental to CBP, and should permeate all aspects of research and practice”
(p. 692). Both of these stands are woven into section 1 of this book, which
addresses the nature of behavioral and cognitive therapies, and are carried forward
in other chapters.
To our knowledge, the present volume is the first CBT text to fully explore
the implications of what the training standards call “overarching scientific ‘world
views’” (p. 691). The training task force argues, we believe correctly, that training
in the various philosophical worldviews underlying different cognitive and behav-
ioral methods is key to having the ability to communicate across its various wings,
waves, and traditions:
Many psychologists may not be aware of the implicit assumptions that

underlie their work, which can lead to considerable confusion and con-
troversy of a sort that impedes progress in the science itself. Different
philosophies of science (and especially the epistemologies represented by
those philosophical systems) lead not only to different methods of inquiry,
but also to different interpretations of data, including at times different
interpretations of the very same data. Failure to appreciate differences in
preanalytic assumptions can lead to frustration among scholars and prac-
titioners alike, who become puzzled when their colleagues fail to be con-
vinced of the implications of certain clinical observations or research
findings. Lack of awareness of one’s philosophical assumptions also pre-
cludes critical examination and comparison of alternative philosophies of
science. (p. 691)
The task force listed seventeen core clinical competencies of known impor-
tance and suggested that the focus of education should be on “training in the
basic principles behind [these] interventions” (p. 696). These principles were
said to emerge from an understanding of several key domains, such as under-
standing learning theory, cognition, emotion, the therapeutic relationship, and
neuroscience.
2
Introduction
These guidelines are a key focus in this volume. This book includes chapters
for all of the core clinical competencies mentioned in the standards and all of the
key process domains, as well as a chapter on evolution science. For each clinical
competency, the authors also attempted to focus on core processes and principles
that account for the impact of these methods.
We believe that examining evidence-based intervention in light of the ideas
in the new training standards allows the field to redefine evidence-based therapy
to mean the targeting of evidence-based process with evidence-based procedures
that alleviate the problems and promote the prosperity of people. We believe that
a focus on process-based therapy will guide the field far into the future. Identifying
core processes will enable us to avoid the constraints of using protocol for syn-
dromes as the primary empirical approach to treatment and instead allow us to
directly link treatment to theory.
We hope this text serves as one important step in this direction. We intend
for it to serve as a reference and graduate text in clinical intervention for behav-
ioral and cognitive therapies, broadly defined. We believe it provides practitioners,
researchers, interns, and students with a thorough review of the core processes
involved in contemporary behavioral and cognitive therapies and, to some degree,
in evidence-based therapy more generally. The focus on evidence-based compe-
tencies in this book is designed to make readers step back from the more specific
protocols and skills that are often highlighted in different treatments and to
embrace core processes that are common to many empirically supported approaches.
We explicitly mean for it to span the various traditions and generations of differ-
ent behavioral and cognitive therapies, while at the same time respect what is
unique about their different processes of research and development.
This book is divided into three sections. Section 1 addresses the nature of
behavioral and cognitive therapies and includes chapters on the history of CBT
development—from its inception as a discredited new treatment model to its posi-
tion today at the forefront of evidence-based therapies, philosophy of science,
ethics, and the changing role of practice. Section 2 focuses on the principles,
domains, and areas that serve as the theoretical foundations of CBT as a collec-
tion of empirically supported treatments; these principles, domains, and areas
include behavioral principles, cognition, emotion, neuroscience, and evolution
science. Section 3 discusses the core clinical competencies that make up the bulk
of CBT interventions, including contingency management, stimulus control,
shaping, self-management, arousal reduction, coping and emotion regulation,
problem solving, exposure strategies, behavioral activation, interpersonal skills,
cognitive reappraisal, modifying core beliefs, defusion/distancing, enhancing psy-
chological acceptance, values, mindfulness and integrative approaches, motiva-
tional strategies, and crisis management. Each of these chapters about competencies
3
Process-Based CBT
focuses on the known mediator and moderators that link these methods to the
process domains and principles described earlier in the book. The book ends with
a summary of what we’ve learned and future directions for this field.
We, the two editors of this textbook, might seem like an odd couple. In fact,
we are an odd couple. Although both of us served as president of ABCT, our
philosophical backgrounds are quite different. We are both considered prominent
figures in the communities representing the two seemingly opposing camps in
contemporary CBT: the acceptance and commitment therapy/new generation
CBT (Hayes) and the Beckian/more traditional CBT (Hofmann). After a stormy
beginning with countless heated debates during panel discussions (often resem-
bling the academic version of boxing matches or wrestling events) and in writing,
we became close friends and collaborators. We have been continuously working
to identify common ground while respecting our differences and points of view.
Our mutual goal has always been the same: moving the science and practice of
clinical intervention forward.
Because of our status in different wings of the field, we were able to assemble
a diverse and stellar group of contributing authors. They have been able to
combine their expertise to produce this groundbreaking, contemporary text that
brings together the best of behavior therapy, behavior analysis, cognitive therapy,
and acceptance-and mindfulness-based therapies, emphasizing the core processes
of change in intervention that every clinician should know. We hope it helps set
the stage for a new era of process-based therapy that will move the field beyond its
era of silos toward an era of scientific progress that will positively impact the lives
of those we serve.
References
Klepac, R. K., Ronan, G. F., Andrasik, F., Arnold, K. D., Belar, C. D., Berry, S. L., et al. (2012).
Guidelines for cognitive behavioral training within doctoral psychology programs in the
United States: Report of the Inter-Organizational Task Force on Cognitive and Behavioral
Psychology Doctoral Education. Behavior Therapy, 43(4), 687–697.
4
PART 1
CHAPTER 1
The History and Current Status of CBT

as an Evidence-Based Therapy
Stefan G. Hofmann, PhD

Department of Psychological and Brain Sciences,
Boston University
Steven C. Hayes, PhD

Department of Psychology, University of Nevada, Reno
The Inter-Organizational Task Force on Cognitive and Behavioral Psychology

Doctoral Education, organized by the Association for Behavioral and Cognitive
Therapies (Klepac et al., 2012), marks an important step in the arduous journey
of clinical psychology toward a mature applied science. The task force developed
guidelines for integrated education and training in cognitive and behavioral psy-
chology at the doctoral level in the United States, which seem to us to open up
important avenues of training.
A series of important consensus processes has marked the development of
evidence-based intervention approaches. A milestone on this journey was the
1949 Boulder conference, which officially recognized that clinical psychology
training should emphasize both the practice and the science of the profession
(Raimy, 1950). Soon after, in 1952, Hans-Jürgen Eysenck delivered a somber chal-
lenge to the nascent field of clinical psychological science in his review of the
effectiveness of adult psychotherapies, concluding that psychotherapy was not
more effective in treating clients than the simple passage of time:
In general, certain conclusions are possible from these data. They fail to
prove that psychotherapy, Freudian or otherwise, facilitates the recovery
of neurotic patients. They show that roughly two-thirds of a group of neu-
rotic patients will recover or improve to a marked extent within about
Process-Based CBT
two years of the onset of their illness, whether they are treated by means
of psychotherapy or not. This figure appears to be remarkably stable from
one investigation to another, regardless of type of patient treated, stan-
dard of recovery employed, or method of therapy used. From the point of
view of the neurotic, these figures are encouraging; from the point of view
of the psychotherapist, they can hardly be called very favorable to his
claims. (pp. 322–323)
Eysenck was known for his strong bias against psychoanalysis, and the devel-
opment of behavior therapy was, at least in part, an attempt to rise to his chal-
lenge. The first behavior therapy journal, Behaviour Research and Therapy,
appeared in 1965, and within a few years Eysenck’s original question—Does psy-
chotherapy work?—changed to a much more specific and difficult question (Paul,
1969, p. 44): “What treatment, by whom, is most effective for this individual with
that specific problem, and under which set of circumstances, and how does it
come about?” Behavior therapists, and later, cognitive behavioral therapists,
pursued at least part of that question by studying protocols of various specific
disorders and problems.
By the time Smith and Glass (1977) performed the first meta-analysis of psy-
chotherapy outcomes, they were able to examine 375 studies, representing approx-
imately 25,000 subjects, and to calculate an effect-size analysis based on 833
effect-size measures. The results of this impressive analysis show clear evidence of
the efficacy of psychotherapy beyond merely waiting. On average, a typical patient
receiving any form of psychotherapy was better off than 75 percent of untreated
people, and overall the various forms of psychotherapy (systematic desensitiza-
tion, behavior modification, Rogerian, psychodynamic, rational emotive, transac-
tional analysis, and so on) were equally effective.
Since then, psychotherapy research has evolved considerably. Enhancements
have been made in clinical methodologies and research design, our understanding
of diverse psychopathologies, psychiatric nosology, and assessment and treatment
techniques. Government agencies, insurance companies, and patient advocate
groups have begun to demand that psychological interventions be based on evi-
dence. In line with the more general move toward evidence-based medicine
(Sackett, Strauss, Richardson, Rosenberg, & Haynes, 2000), in psychotherapy the
term evidence-based practice considers the best available research evidence for the
effectiveness of a treatment, the specific patient characteristics of those receiving
the treatment, and the clinical expertise of the therapist delivering the treatment
(American Psychological Association Presidential Task Force on Evidence-Based
Practice, 2006). Various agencies and associations worldwide have begun compil-
ing lists of evidence-based psychotherapy methods, such as the National Registry
8
The History and Current Status of CBT as an Evidence-Based Ther apy
of Evidence-based Programs and Practices (NREPP) of the US Substance Abuse

and Mental Health Services Administration.
In a highly influential step in 1995, the Society of Clinical Psychology
(Division 12 of the American Psychological Association) created a Task Force on
Promotion and Dissemination of Psychological Procedures with the goal of devel-
oping a list of research-supported psychological treatments (RSPTs; earlier names
for this list were evidence-supported treatments and evidence-based treatments).
It should be noted that the Division 12 task force deliberately recruited clinicians
and researchers from a number of different theoretical orientations, including psy-
chodynamic, interpersonal, cognitive behavioral, and systemic points of view, in
order to avoid allegiance biases (Ollendick, Muris, & Essau, in press).
The Division 12 task force published its first report in 1995, in which it
included three categories of RSPTs: (1) well-established treatments, (2) probably
efficacious treatments, and (3) experimental treatments. Well-established treat-
ments had to be superior to a psychological placebo, drug, or other treatment,
whereas the probably efficacious treatments had to be superior only to a wait-list
or no-treatment control condition. Well-established treatments were also required
to have evidence from at least two different investigatory teams, whereas probably
efficacious treatments were required to have evidence from only one investigatory
team. Moreover, the task force required that all treatments specify patient char-
acteristics (such as age, sex, ethnicity, diagnosis, etc.) and that treatment manuals
explain the specific treatment strategies. Although not strictly required, the list of
RSPTs was largely based on treatments for specific disorders defined by the
Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric
Association, 2000, 2013).
Finally, it was necessary for treatments to demonstrate clinical outcomes in
well-controlled clinical trials or in a series of well-controlled single-case designs.
The quality of the designs had to be such that the benefits observed were not due
to chance or confounding factors, such as the passage of time, the effects of psy-
chological assessment, or the presence of different types of clients in the various
treatment conditions (Chambless & Hollon, 1998). This system of treatment cat-
egorization was intended to be a work in progress. Consistent with this goal, the
list of RSPTs was placed online and is now maintained and updated at http://
www.div12.org/psychological-treatments/treatments.
Most recently, the criteria for RSPTs were revised to include evidence from
meta-analytic reviews of multiple trials across multiple domains of functioning
(Tolin, McKay, Forman, Klonsky, & Thombs, 2015). Of all treatments, cognitive
behavioral therapy (CBT) has by far the largest evidence base. A review of the
efficacy of CBT for mental disorders easily filled a large three-volume textbook
series (Hofmann, 2014b). It should be noted, however, that some disorders are
9
Process-Based CBT
more responsive to existing CBT methods than others. In the case of anxiety
disorders, for example, a meta-analysis of methodologically rigorous, randomized,
placebo-controlled studies reported that CBT yields the largest effect sizes for
obsessive-compulsive disorder and acute stress disorder but only small effect sizes
for panic disorder (Hofmann & Smits, 2008). Moreover, some CBT protocols
show disorder specificity; for example, depression changes to a significantly lesser
degree than anxiety with a protocol targeting anxiety disorders, and the reverse is
true for depressive disorders. This clearly speaks against the argument that CBT
lacks treatment specificity. At the same time, this and many other meta-analyses
show that there is clearly a lot of room for improvement with contemporary CBT
(Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012).
Despite the well-planned and executed mission, the Division 12 task force
report and its list-supported treatments generated heated debates and arguments.
Some of the counterarguments focused on fears that the use of treatment manuals
would lead to mechanical, inflexible interventions and a loss of creativity and
innovation in the therapy process. Another frequently made argument was that
treatments that were effective in clinical research settings might not be transport-
able to “real-life” clinical practice settings with more difficult or comorbid clients
(for a review, see Chambless & Ollendick, 2001). The strong representation of
CBT protocols (in contrast to psychodynamically or humanistically oriented ther-
apies) among the treatments meeting the RSPT criteria also fueled the intensity
of the debates. A final major concern for some psychotherapists was the align-
ment of empirically supported treatments with specific diagnostic categories.
For example, consider the difference between CBT and psychodynamically
oriented therapies. Instead of trying to identify and resolve hidden conflicts, CBT
practitioners could encourage clients to utilize more-adaptive strategies to deal
with their present psychological problems. As a result of this relative concordance,
CBT protocols were developed for virtually every category of the DSM and the
tenth revision of the International Statistical Classification of Diseases and Related
Health Problems (ICD-10; World Health Organization, 1992–1994).
A recent review of the literature identified no fewer than 269 meta-analytic
studies examining CBT for nearly every DSM category (Hofmann, Asnaani et al.,
2012). In general, the evidence base of CBT is very strong, especially for anxiety
disorders, somatoform disorders, bulimia, anger control problems, and general
stress, because CBT protocols closely align with the different psychiatric catego-
ries. Although generally efficacious, there are clear differences in the degree of
CBT’s efficacy across disorders. For example, major depressive disorder and panic
disorder manifest a relatively high placebo-response rate. Such disorders run a
fluctuating and recurring course so that the important question is not so much
what are the short-term outcomes, since many treatments may work initially, but
10
rather how effective are treatments in preventing relapse and recurrence in the
longer term (Hollon, Stewart, & Strunk, 2006).
The focus on DSM-defined psychiatric disorders has sometimes limited the
vision of CBT in its measures and application. For example, with CBT, measures
of flourishing, quality of life, prosociality, relationship quality, or other issues that
are more focused on growth and prosperity are often less in focus despite client
interest in such issues. This limited vision is especially true of behavioral mea-
sures, which is unfortunate, because we know that some of the methods used in
evidence-based therapy are applicable to health and prosperity issues.
The focus on disorders has led to a proliferation of specific protocols that can
make training difficult and can limit the integration of research and clinical lit-
erature. Practitioners can get lost in a sea of supposedly distinctive but often over-
lapping methods.
These issues of breadth of focus, long-term effects, and protocol proliferation
touch upon some fundamental ideas about the nature of psychological function-
ing and of treatment goals. It is the claim of this volume that the field needs a
course correction to rise to the challenges of the present moment.
Problems with the Biomedical Model

The development and refinement of CBT models for the various DSM and ICD-10
diagnoses has permitted therapists and researchers to apply specific treatment
techniques across a diverse range of psychopathologies. However, the general
alignment of CBT protocols with the medical classification system of mental dis-
orders has had downsides (e.g., Deacon, 2013). For example, classifying people
using criteria-based psychiatric diagnostic categories based on presenting symp-
toms minimizes or ignores contextual and situational factors contributing to the
problem (e.g., Hofmann, 2014a). Modern CBT often overemphasizes techniques
for specific symptoms at the expense of theory and case conceptualization, limit-
ing the further development of CBT. Health promotion and the whole person can
become less of a focus as syndromal thinking dominates. CBT is not at an end
state; rather, it needs to continue to evolve with time, generating testable models
(Hofmann, Asmundson, & Beck, 2013) and novel treatment strategies (e.g.,
Hayes, Follette, & Linehan, 2004).
Some authors argue that clinical researchers developing research-based inter-
ventions largely ignore common factors (as opposed to specific treatment strate-
gies), and that these factors are primarily responsible for therapeutic change
(Laska, Gurman, & Wampold, 2014). Approaching this issue as a dichotomy
appears to be an error. It is actually relatively common for clinical researchers
11
Process-Based CBT
developing empirically supported treatments to consider these factors by examin-

ing the effects of, for example, the therapeutic alliance in outcomes. The impact
of common factors varies from disorder to disorder, and although they can be
important, they alone are not sufficient to produce the maximum effects on treat-
ment outcomes. Furthermore, relationship factors can be responsive to the same
psychological processes that evidence-based methods target. This suggests that
the theoretically coherent processes addressed by CBT may in part account for
some common factors. For example, the mediating relationship of the working
alliance is no longer significant to outcome if a client’s psychological flexibility is
added as an additional mediator (e.g., Gifford et al., 2011), suggesting that the
therapeutic alliance works in part by modeling acceptance, nonjudgment, and
similar processes that may be targeted in modern CBT methods.
Much of the data on the therapeutic alliance is correlational and points to
relatively immutable features, such as therapist variables. Common factors become
central to practitioners, however, when specific methods to change them are
developed and tested against other evidence-based methods. That kind of work is
just beginning, and to conduct that work better, therapists need to develop theo-
ries about the therapeutic alliance and how, concretely, to change it—precisely
the kinds of areas where CBT and evidence-based therapy can be helpful.
It is time for clinical psychology and psychiatry to move beyond picking either
common factors or evidence-based psychological treatments in an all-or-none
analysis (Hofmann & Barlow, 2014). Instead, we need to isolate and understand
the effective processes of change and how best to target them, with relationship
factors treated as one such process. This approach will allow the field to focus on
any issue that will help our clients improve their lives and will help advance our
scientific discipline.
Defining the Targets of Psychotherapy and

Psychological Intervention
In the early days of behavior therapy, specific problems or specific positive growth
targets were often the aim of the intervention, but with the rise of the DSM, syn-
drome and mental disorders became more of a focus. Clinical scientists have
engaged in a long and heated debate over how to best define and classify mental
disorders (e.g., Varga, 2011). The structure of the DSM-5 and ICD-10 is firmly
rooted in the biomedical model, assuming that signs and symptoms reflect under-
lying and latent disease entities. Earlier versions of these manuals were grounded
in psychoanalytic theory, assuming that mental disorders are rooted in deep-
seated conflicts. In contrast, the modern versions implicate dysfunctions in
12
genetic, biological, psychological, and developmental processes as the primary

causes of a mental disorder.
A prominent sociobiological definition of the term mental disorder is “harmful
dysfunction” (Wakefield, 1992). The problem is considered a “dysfunction”
because having it means that the person cannot perform a natural function as
designed by evolution; the problem is considered “harmful” because it has nega-
tive consequences for the person, and society views the dysfunction negatively.
Not surprisingly, this definition is not without criticism because it is unclear
how to define and determine the function or dysfunction of a behavior (e.g.,
McNally, 2011). Early critics (e.g., Szasz, 1961) argued that psychiatric disorders
are simply labels that society attaches to normal human experiences and represent
essentially arbitrary social constructions without any functional value. The same
phenomenon that is considered abnormal in one culture or at one point in history
may be considered normal or even desirable in another culture or at another point
in history.
The official definition of a mental disorder in the DSM is “a syndrome charac-
terized by clinically significant disturbance in an individual’s cognition, emotion
regulation, or behavior that reflects a dysfunction in the psychological, biological,
or developmental processes underlying mental functioning” (American Psychiatric
Association, 2013, p. 20). Although this definition specifically mentions psycho-
logical and developmental processes as possible primary causes in addition to
biological ones, psychiatry has long operated primarily within a biomedical

framework.
The cognitive behavioral approach is most commonly based on a diathesis-
stress model, which assumes that an individual’s vulnerability factors in conjunc-
tion with particular environmental factors or stressors can lead to the development
of the disorder. This perspective makes a critical distinction between initiating
factors (i.e., the factors that contribute to the development of a problem) and
maintaining factors (i.e., the factors that are responsible for the maintenance of a
problem) (Hofmann, 2011). These two sets of factors are typically not the same.
Unlike other theoretical models of mental disorders, CBT is generally more con-
cerned about the maintenance factors because they are the targets of effective
treatments for present impairments. Therefore, from a CBT perspective, classify-
ing individuals based on maintenance factors is likely to be of far greater impor-
tance than classifying individuals based on vulnerabilities alone, such as genetic
factors or brain circuits.
This emphasis is broadly in line with the developmental approach of the
behavioral tradition, which may not emphasize vulnerabilities and stressors but
recognizes that the historical factors that led to a problem may differ from the
environmental factors that maintain it. Functional analysis is focused on
13
Process-Based CBT
maintaining factors for current behaviors precisely because it is these that need to
change in order to improve an individual’s mental health.
Why Classify Mental Disorders?

Proponents of the DSM often point out that a psychiatric classification
system, no matter how imprecise, is a necessity for the following reasons: First, it
provides the field with a common language to describe individuals with psycho-
logical problems. This is of great practical value because it simplifies communica-
tion among practitioners and provides a coding system for insurance companies.
Second, it advances clinical science by grouping together people with similar
problems in order to identify common patterns and isolate features that distin-
guish them from other groups. Third, this information may be used to improve
existing treatments or to develop new interventions. This latter purpose is
acknowledged by the DSM-5, which states, “The diagnosis of a mental disorder
should have clinical utility: it should help clinicians to determine prognosis, treat-
ment plans, and potential treatment outcomes for their patients” (American
Psychiatric Association, 2013, p. 20). Despite these lofty goals, however, the
DSM-5 offered little new or different material from its predecessors, sparking a
great degree of dissatisfaction in the medical and research community.
Aside from political and financial issues (the DSM is a major source of income
for the American Psychiatric Association), there are many theoretical and con-
ceptual problems with the DSM. For example, it pathologizes normality using
arbitrary cut points; a diagnosis made using the DSM is merely based on subjec-
tive judgment by a clinician rather than objective measures; it is overly focused on
symptoms; its categories describe a heterogeneous group of individuals and a large
number of different symptom combinations that define the same diagnosis, and
most clinicians continue to use the residual diagnosis (“not otherwise specified”)
because most clients do not fall neatly into any of the diagnostic categories, which
are derived by consensus agreement of experts (for a review, see Gornall, 2013).
Perhaps one of the biggest conceptual problems is comorbidity (i.e., the
co-occurrence of two or more different diagnoses). Comorbidity is inconsistent
with the basic notion that symptoms of a disorder reflect the existence of a latent
disease entity. If disorders were in fact distinct disease entities, comorbidity should
be an exception in nosology. However, disorders are commonly comorbid. For
example, among mood and anxiety disorders, the DSM-5 posits that virtually all
of the considerable covariance among latent variables corresponding to its
constructs of unipolar depression, generalized anxiety disorder, social anxiety
disorder, obsessive-compulsive disorder, panic disorder, and agoraphobia can be
14
explained by the higher-order dimensions of negative and positive affect; this

suggests that mood and anxiety disorders emerge from shared psychosocial and
biological/genetic diatheses (Brown & Barlow, 2009).
Observations like these served as the basis for recent efforts to develop
so-called transdiagnostic (Norton, 2012) or unified (Barlow et al., 2010) treat-
ment protocols that cut across diagnostic categories to address the core features of
disorders, the goal being to develop more parsimonious and, perhaps, powerful
treatments (Barlow, Allen, & Choate, 2004). In addition, this approach might
counter the drawback of training clinicians in disorder-specific CBT protocols,
which often leads to an oversimplification of human suffering, inflexibility on the
part of the clinician, and low adherence to evidence-based practices (McHugh,
Murray, & Barlow, 2009).
Research Domain Criteria

In an attempt to offer a solution to the nosology problems associated with the
DSM (and the ICD-10), the National Institute of Mental Health (NIMH) devel-
oped the Research Domain Criteria (RDoC) Initiative, a new framework for clas-
sifying mental disorders based on dimensions of observable behavior and
neurobiological measures (Insel et al., 2010). This initiative is an attempt to move
the field of psychiatry forward by creating a classification system that conceptual-
izes mental illnesses as brain disorders. In contrast to neurological disorders with
identifiable lesions, mental disorders are considered disorders with abnormal brain
circuits (Insel et al., 2010). Instead of relying on clinical impressions, resulting in
arbitrarily defined categories that comprise heterogeneous and overlapping diag-
nostic groups, the NIMH suggests integrating the findings of modern brain
sciences in order to define and diagnose mental disorders (Insel et al., 2010).
The stated goal of this project is to develop a classification system for mental
disorders based on biobehavioral dimensions that cut across current heteroge-
neous DSM categories. The RDoC framework assumes that dysfunctions in
neural circuits can be identified with the tools of clinical neuroscience, including
electrophysiology, functional neuroimaging, and new methods for quantifying
connections in vivo. The framework further assumes that data from genetics and
clinical neuroscience will yield biosignatures that can augment the clinical symp-
toms and signs used for clinical management. For example, in the case of anxiety
disorders, the practitioner of the future would utilize data from functional or
structural imaging, genomic sequencing, and laboratory-based evaluations of fear
conditioning and extinction to determine a prognosis and appropriate treatment
(Insel et al., 2010). The concrete product of the RDoC initiative is a matrix that
15
Process-Based CBT
lists different levels (molecular, brain circuit, behavioral, and symptom) of analysis
in order to define constructs that are assumed to be the core symptoms of mental
disorders.
Whereas neuroscientists generally applauded the RDoC initiative (Casey et
al., 2013), others criticized it for various reasons. For example, the project overem-
phasizes certain kinds of biological processes, reducing mental health problems to
simple brain disorders (Deacon, 2013; Miller, 2010). So far the RDoC has had
limited clinical utility because it is primarily intended to advance future research,
not to guide clinical decision making (Cuthbert & Kozak, 2013). Moreover, the
RDoC initiative shares with the DSM the strong theoretical assumption that
psychological problems (“symptoms”) are caused by a latent disease. In the case of
the DSM, these latent disease entities are measured through symptom reports and
clinical impressions, whereas in the case of the RDoC they are measured through
sophisticated behavioral tests (e.g., genetic tests) and biological instruments (e.g.,
neuroimaging).
Moving Toward Core Dimensions in

Psychopathology
In the last few decades, considerable progress has been made to identify core
dimensions of psychopathology. The RDoC initiative proposes such a dimen-
sional classification system. Similarly, psychologists have been reconsidering
dimensions of psychopathology. For example, in the case of emotional disorders,
numerous authors have identified emotion dysregulation as one of the core trans-
diagnostic problems (Barlow et al., 2004; Hayes, Luoma, Bond, Masuda, & Lillis,
2006; Hayes, Strosahl, & Wilson, 1999; Hofmann, Asnaani et al., 2012; Hofmann,
Sawyer, Fang, & Asnaani, 2012). This is fully consistent with contemporary
emotion research, such as the process model described by Gross (1998). Gross’s
emotion-generative process model of emotions posits that emotion-relevant cues
are processed to activate physiological, behavioral, and experiential responses,
and that these responses are modulated by emotion regulation tendencies.
Depending on the time point at which a person engages in emotion regulation,
the techniques are either antecedent- focused or response- focused strategies.
Antecedent-focused emotion regulation strategies include cognitive reappraisal,
situation modification, and attention deployment and occur before the emotional
response has been fully activated. In contrast, response-focused emotion regula-
tion strategies, such as strategies to suppress or tolerate the response, are attempts
to alter the expression or experience of an emotion after the response has been
initiated.
16
There are many more pathology dimensions that cut across DSM-defined
disorders, such as negative affect, impulse control, attentional control, rumination
and worrying, cognitive flexibility, self-awareness, or approach-based motivation
to name only a few. As these dimensions have become more central to the under-
standing of psychopathology, it has become clearer that employing in a flexible
manner the strategies that are most appropriate for a given context and goal
pursuit is the most adaptive method for long-term adjustment (Bonanno, Papa,
Lalande, Westphal, & Coifman, 2004). Many forms of psychopathology are asso-
ciated with the negatively valenced responses, such as fear, sadness, anger, or
distress, but all of these play a positive role in life. No psychological reaction, and
no strategy for addressing a psychological reaction, is consistently adaptive or mal-
adaptive (Haines et al., 2016). The goal of modern CBT is not to eliminate or
suppress feelings, thoughts, sensations, or memories—it is to promote more posi-
tive life trajectories. Learning how best to target relevant processes that foster
positive growth and development is the challenge of modern intervention science
and the focus of this volume.
Moving Toward Core Processes in CBT

It appears that the fundamental question of psychotherapy research formulated by
Hans-Jürgen Eysenck (1952), and then revised by Gordon Paul (1969), needs to be
revised yet again. The core question is no longer whether intervention works in a
global way, nor is it how to make effective technological decisions in a contextu-
ally specific manner. The first question has been answered, and the technological
emphasis of the second has led to a proliferation of methods that are difficult to
systematize in a progressive fashion. Because of their failure to identify function-
ally distinct entities, both the purely syndromal focus and the largely technologi-
cal approach need to be de-emphasized.
The movement toward the RDoC contains a key aspect that seems to fit this
moment of evolution in the field of psychotherapy. The complex network approach
also offers another potentially promising new perspective on psychopathology and
treatment (Hofmann, Curtiss, & McNally, 2016). Instead of assuming that mental
disorders arise from underlying disease entities, the complex network approach
holds that these disorders exist due to a network of interrelated elements. An
effective therapy may change the structure of the network from a pathological to
a nonpathological state by targeting core processes. Similar to traditional func-
tional analysis, we need to understand the causal relationship between stimuli
and responses in order to identify and target these core processes of pathology and
17
Process-Based CBT
change in a contextually specific way. Longitudinal designs are allowing clini-

cians to develop targeted and specific measures that predict the development of
psychopathology over time (e.g., Westin, Hayes, & Andersson, 2008). Clinicians
can target these measures for change using evidence-based methods and deter-
mine the mediating role of change in these processes (e.g., Hesser, Westin, Hayes,
& Andersson, 2009; Zettle, Rains, & Hayes, 2011).
By combining strategies, such as RDoC, functional analysis, the complex
network approach, and longitudinal design, researchers are making progress in
identifying the core processes of change in psychotherapy and psychological inter-
vention (Hayes et al., 2006). With increasing knowledge of the components that
move targeted processes (e.g., Levin, Hildebrandt, Lillis, & Hayes, 2012), research-
ers are building on that foundation. The goal is to learn which core biopsychoso-
cial processes should be targeted with a given client who has a given goal in a
given situation, and to then identify the component methods most likely to change
those processes.
The identification of core processes in psychotherapy will guide psychothera-
pists into the future. These processes will allow us to avoid the constraints of
treatment protocols based on a rigid and arbitrary diagnostic system and will
directly link treatment to theory. This vision is what animates the present
volume—that is, creating a more process-based form of CBT and evidence-based
therapy. This vision pulls together many trends that already exist in the field and
builds on the strengths of the many traditions and generations of work that make
up the cognitive and behavioral approaches to therapy.
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21
CHAPTER 2
The Philosophy of Science As It

Applies to Clinical Psychology
Sean Hughes, PhD

Department of Experimental Clinical and Health Psychology,
Ghent University
Introduction
Imagine three scientists out to expand the limits of human understanding. The
first is an astronaut busy analyzing soil samples on the cold, dark surface of the
moon. The second is a marine biologist trying to find ways to get penguins more
active and engaged at a large public aquarium. The third is a primatologist deeply
interested in the courting behavior of silverback gorillas, who finds herself wading
through a tropical forest in Central Africa. Although all three use the scientific
method to understand a specific phenomenon, they approach their goals in very
different ways. The fundamental questions they are interested in (e.g., What is
the lunar soil composed of? How can the behavior of captive penguins be changed?
How do primates behave socially in the wild?) will guide the procedures they use,
the theories they generate, the types of data they collect, and the answers they
ultimately find satisfactory.
In many ways, clinical psychological science faces a similar situation. Although
clinicians and researchers are united by a shared goal (to understand how human
suffering can be alleviated and well-being promoted), they often tackle that goal
in fundamentally different ways. Some argue that this goal can be best achieved
by detecting and correcting the dysfunctional beliefs, pathological cognitive
schemas, or faulty information- processing styles that underpin psychological
The Ghent University Methusalem Grant BOF16/MET_V/002, presented to Jan De Houwer, sup-
ported the preparation of this chapter. Correspondence concerning this chapter should be addressed
to sean.hughes@ugent.be.
Process-Based CBT
suffering (e.g., Beck, 1993; Ellis & Dryden, 2007). Others counter that the best
solution requires that we contact and alter the functions of internal events rather
than their particular form or frequency (e.g., Hayes, Strosahl, & Wilson, 1999;
Linehan, 1993; Segal, Williams, & Teasdale, 2001). In this rich, dense jungle of
clinical research and theorizing, different traditions often find themselves in fierce
competition, with proponents of one perspective arguing for the logical suprem-
acy of their own procedures, findings, theories, and therapies, while others respond
with equally and strongly held convictions (see Reyna, 1995, for an example). In
such an environment, you might ask yourself, Is there really a “best” solution to the
problem of psychological suffering? How do clinicians and researchers define what
qualifies as “best,” and is this a subjective or objective choice? How do they actu-
ally determine whether a given procedure, finding, theory, or therapy is satisfac-
tory or even better than others?
Even if clinical researchers do not typically operate in the cold vacuum of
outer space, the water tanks of an aquarium, or the humid interiors of tropical
forests, their activities are nevertheless carried out within a larger context that
guides their scientific values and goals. One of the more important aspects of this
context is their philosophical worldview. Worldviews specify the nature and
purpose of science, causality, data, and explanation. They define what we con-
sider the proper subject matter of our field, what our units of analysis will be, the
types of theories and therapies we build and evaluate, the methodologies we con-
struct, and how findings should be generated and interpreted.
Questions about ontology, epistemology, and axiology can seem highly
abstract and far removed from the daily trials and tribulations that make up clini-
cal research or therapeutic practice. In what follows I aim to demonstrate how
philosophical assumptions are similar to the air we breathe: typically invisible,
integral to our daily functioning, and yet often taken for granted. There is no
privileged place that allows you to avoid these issues: your worldview silently
shapes how you think and act, influencing the theories, therapies, techniques,
and data you consider convincing or valid (e.g., Babbage & Ronan, 2000; Forsyth,
2016). It dictates some of your moment-to-moment behavior when interacting
with a client. By properly articulating and organizing these assumptions, you gain
access to a powerful method of determining the internal consistency of your own
scientific views and ensure that your efforts at knowledge development are
progressive—when measured against your (clinical) scientific goals.
Scientific endeavors must have criteria to evaluate competing theoretical and
methodological accounts if progress is to be achieved. Yet scholars often engage in
debates of a different kind: ones that center on the legitimacy, primacy, and value
of one intellectual tradition relative to another. Such debates have been labeled
“pseudoconflicts,” given that they involve applying the philosophical assumptions
24
The Philosophy of Science As It Applies to Clinical Psychology
(and thus scientific goals and values) of one’s own approach to the assumptions,
goals, and values of others (Pepper, 1942; Hayes, Hayes, & Reese, 1988). For
instance, behaviorally oriented therapists may dismiss the value of mental-
mediating representations and processes, such as cognitive schemas or biases,
given that such explanatory constructs are counter (or even irrelevant) to their
own focus on manipulable, contextual variables that can facilitate the prediction
and influence of psychological events. Similarly, cognitively oriented researchers
might view any analysis that omits reference to the mental machinery of the mind
as merely descriptive and nonexplanatory. As Dougher (1995) notes, these respec-
tive scholars might wonder why their counterparts “persist in taking such outdated
or plainly wrong-headed positions, why they persist in misrepresenting my position,
and why they can’t see that both logic and data render their position clearly infe-
rior” (p. 215). The failure to recognize the philosophical origins of these debates
often leads to “frustration, sarcasm, and even ad hominem attacks on the intellec-
tual or academic competence of those holding alternative positions” (p. 215).
Psychological scientists who are capable of articulating their philosophical
assumptions are better able to identify genuine and productive conflicts within
traditions that drive theory and research forward, and they can avoid wasting
time on pseudoconflicts that tend to be degenerative in nature. In other words,
appreciating the philosophical underpinnings of your work also allows you to
communicate without dogmatism or arrogance to those who hold different
assumptions. Such flexibility is central to the theme of this book: helping differ-
ent wings of evidence-based therapy learn to communicate across philosophical
divides. For these reasons and others, a consortium of cognitive and behavioral
organizations recently added training in philosophy of science to the training
standards for empirical clinicians (Klepac et al., 2012).
Finally, the clinical literature is home to an overwhelming number of perspec-
tives that may tempt students to adopt a vapid form of eclecticism, hoping that by
mixing together all plausible theories and concepts, even better therapeutic out-
comes will be likely. Disciplined combinations of approaches are possible and
helpful, but confusion results if theories and therapies are mixed in ways that are
inconsistent (because underlying philosophical assumptions were misunderstood
or ignored).
This chapter is divided into three sections. Part 1 provides a brief introduc-
tion to the core topics of philosophy of science as they apply to those undergoing
clinical training (examples of more extensive treatments are Gawronski &
Bodenhausen, 2015; Morris, 1988; Guba & Lincoln, 1994; among many others).
In part 2, I introduce a number of worldviews that were originally forwarded by
Stephen Pepper in the 1940s, with a focus on mechanism and contextualism in
particular. I will demonstrate how these latter worldviews have arguably shaped
25
Process-Based CBT
and continue to drive clinical psychology. Finally, in part 3 I consider the topics
of worldview selection, evaluation, communication, and collaboration. If readers
then decide to adopt a particular philosophical perspective, they will do so with
awareness of the alternatives, how this decision shapes their own thinking and
actions, and how they can interact with colleagues who see (or construct) the
world in ways that differ from their own.
Part 1: A Brief Introduction to Philosophy

of Science
Science is broadly concerned with the development of a systematic body of knowl-
edge that is tied to empirically derived evidence (e.g., Lakatos, 1978; Laudan,
1978). This system of knowledge is built with the intention of understanding and
influencing “patterns of relations among phenomena and processes of the experi-
enced world” (Lerner & Damon, 2006, p. 70). Philosophy of science refers to the
conceptual foundation upon which this systematic body of knowledge is built.
Rather than focusing on the particular theories, methods, and observations that
define a scientific domain, philosophy of science is concerned with the scientific
enterprise itself. The goal is to uncover the assumptions that are often implicit (or
taken for granted) in scientific practice and that dictate its course (e.g., how
science should proceed, what methods of inquiry should be used, how much con-
fidence should be placed in the findings generated, and what are the limits of the
knowledge obtained). In this way, philosophy of science provides a perspective
from which to examine and potentially evaluate clinical psychological science.
Philosophical Worldviews
A philosophical worldview can be defined as the coherent set of interrelated
assumptions that provides the preanalytic framework that sets the stage for scien-
tific or therapeutic activity (see Hayes et al., 1988; closely related terms are “para-
digm,” Kuhn, 1962; and “research programme,” Lakatos, 1978). One’s worldview
is a belief system that both describes and prescribes what data, tools, theories,
therapies, participants, and findings are acceptable or unacceptable. The basic
beliefs that make up a worldview typically revolve around the following set of
interrelated questions, with the answers to one question constraining responses to
the others.
The ontological question. Ontology is broadly concerned with the nature, origin,
and structure of reality and “being.” In other words, what does it mean to say that
something is “real,” and is it possible to study reality in an objective manner?
26
Many ontological stances can and have been taken. For illustrative purposes, I’ll
briefly discuss positivism, postpositivism, and constructivism, given their promi-
nence within psychological science, although perspectives other than these are
possible.
Positivism is a reductionistic and deterministic perspective that often involves
a belief in “naïve realism,” the idea that a discoverable reality exists that is gov-
erned by a system of natural laws and mechanisms. Scientific models and theories
are considered useful or valid insofar as they increase our ability to make claims
that refer to entities or relations in a mind-independent reality (i.e., truth as cor-
respondence). This type of “knowledge is conventionally summarized in the form
of time-and context-free generalizations, some of which take the form of cause-
effect laws” (Guba & Lincoln, 1994, p. 109). Scientific progress itself involves the
development of theories in which representational nature gradually converges
upon a single reality.
Postpositivism also assumes that mind-independent reality exists, but it can
only be imperfectly and probabilistically understood by humans due to their biased
intellectual abilities and the fundamentally intractable nature of phenomena.
Postpositivists believe that there is a reality independent of perception and theo-
ries about it but also argue that humans cannot know that reality with absolute
certainty (e.g., see Lincoln, Lynham, & Guba, 2011). Thus, all scientific claims
about reality must be submitted to close scrutiny if we are to converge on an
understanding of reality that is acceptable (if never perfect).
Constructivism, unlike positivism and postpositivism, takes a relativistic onto-
logical stance. A mind-independent reality is substituted for a constructed one:
reality does not exist independently from our perception or theories about it.
Instead we interpret and construct it based on our experiences and interactions
with the social, experiential, historical, and cultural environments in which we
are embedded. Constructed realities are malleable, differ in their content and
sophistication, and are not “true” in any absolute sense of the word. Although
constructivists tend to acknowledge that phenomena exist, they challenge the
extent to which we can rationally know reality outside of our personal perspec-
tives (e.g., see Blaikie, 2007; Lincoln et al., 2011; Von Glasersfeld, 2001). In some
forms of this approach, constructivists simply refuse, on pragmatic grounds, to
view ontological questions as answerable, useful, or necessary (Hayes, 1997).
The epistemological question. Epistemology, the theory of knowledge, is con-

cerned with the acquisition and justification of knowledge (i.e., whether we do or
can know anything, as well as the validity of that knowledge and how we come to
know it). It involves asking questions such as “How certain are we that we have
accumulated knowledge?” and “How can we distinguish this knowledge from
27
Process-Based CBT
belief?” When applied to science, “knowledge” refers to scientific theories, expla-

nations, and laws, and “epistemology” involves answering questions such as “In
what way does evidence support a theory?” or “What does it mean to say that a
theory is true or false?” or “Is the revision and change of theory a rational or irra-
tional process?” Once again, different stances can be taken in the pursuit of sci-
entific knowledge.
Positivism adopts a dualistic and objectivist position: provided that she has
access to the proper methodologies, the knower (scientist) can objectively view
and record events as they “really are” and as they “really work.” This process does
not influence the phenomenon of interest, nor does the phenomenon influence
the knower. Situations in which the knower influences the known (or vice versa)
represent threats to validity, and the knower implements strategies to reduce or
eliminate potential sources of contamination.
Postpositivism is qualified dualist/objectivist. Given the imperfect manner in
which the world is viewed and recorded, dualism is de-emphasized: observations
are accepted as being prone to error and are always open to critique. Theory is
ultimately revisable and open to replacement by a different set of categories and
relationships. However, objectivism is still the “regulatory ideal” to which the
scientist strives (Lincoln et al., 2011). Scientific analyses are considered to be
“true” or “valid” insofar as they allow us to converge on an accurate (if imperfect)
understanding of reality (i.e., truth is correspondence). Such analyses are based on
the idea that (a) knowledge can be best obtained through the identification of
regularities and causal relationships between the component mechanisms that
constitute reality; that (b) these regularities and relationships will be easier to
identify when the scientist and phenomenon do not contaminate one another;
and that (c) the scientific method is the best tool the scientist has to minimize
such contamination. Thus, the purpose of models and theories is to provide
general explanations that are logically organized and that have clearly established
links with the observable world. These explanations extend beyond the observa-
tion of individual events and have a heuristic and predictive function.
Finally, constructivism is transactional and subjective. It argues that findings
are obtained through the interaction of the knower and the known, and as such
they are literally created as the scientific enterprise unfolds. In this way knowl-
edge is subjective insofar as there is no objective location from which to view or
obtain knowledge (and even if there was, we have no way of accessing it). Thus,
the knower is an active participant rather than a passive observer in the knowl-
edge acquisition and justification process. Truth is not correspondence with some
underlying reality but rather the extent to which a particular analysis occasions
“successful working” or is considered “viable.” As Von Glasersfeld puts it, “To the
constructivist, concepts, models, theories…are viable if they prove adequate in
28
the contexts in which they were created” (1995, p. 4). From the constructivist
perspective, science can be viewed as “a corpus of rules for effective action, and
there is a special sense in which it could be ‘true’ if it yields the most effective
action possible” (Skinner, 1974, p. 235; see also Barnes-Holmes, 2000).
The axiology question. Axiology refers to the relationship between knowledge

and human values. When applied to science, it involves questions such as “How
do values relate to (scientific) facts?” and “What role, if any, do the researcher’s
values play in the scientific process?” According to positivism, the scientist views
reality through a one-sided mirror: objectively and impartially. Values and biases
have no place in the scientific process and should be prevented from influencing
one’s activity at all costs. Implementing appropriate methodologies and concep-
tual controls ensures that scientific products are value free.
Postpositivism takes a similar if qualified stance: all observations are assumed
to be theory laden. The search for absolute truth is abandoned and the researcher
accepts that analyses are guided by the cultural, social, historical, and personal
expectancies she brings to the enterprise (i.e., science is value laden). Nevertheless,
progress can be best achieved if the scientist does her utmost to minimize the
impact of such contaminating factors on theoretical arguments and empirical
findings.
Finally, constructivism is dialectical: given the variable and personal nature
of the constructed world, there is no objective location from which reality can be
independently observed or recorded. The scientist cannot be separated from
subject matter, nor can theory be separated from practice. Thus, values are con-
sidered an integral element of the interactions between scientist and the phenom-
enon being studied.
The methodology question. Once the knower (scientist) has determined what
can be known, she must then identify a set of tools that are appropriate for gener-
ating that knowledge. Not just any methodology will suffice. For positivists, meth-
odology should be experimental and manipulative. A mind-independent reality
that can be objectively known requires methodologies that can tap into such a
reality free from the control of confounding factors. A mind-independent reality
also requires that “questions and/or hypotheses be stated in propositional form
and subjected to empirical tests to verify them; possible confounding conditions
must be carefully controlled [manipulated] to prevent outcomes from being
improperly influenced” (Guba & Lincoln, 1994, p. 110).
Postpositivists share a similar view. However, given that all measurement is
subject to error, the researcher must engage in a process of critical multiplism, in
which she takes multiple observations and measurements (that are each subject to
29
Process-Based CBT
different types of error), in order to identify potential sources of error, and then
creates control for them, thus better approximating reality. Through independent
replication the scientist learns more about the ontological validity of her model.
This in turn enables her to engage in the falsification (rather than verification) of
hypotheses and theories.
Constructivism challenges the idea that knowledge exists freely in the world
and that objective measurement procedures can be designed to capture such a
world. All information is subject to interpretation by the researcher and, as such,
the relationship between the researcher and subject matter is a central focus of
methodology.
Philosophical assumptions are interactive. Note that questions about episte-

mology, ontology, axiology, and methodology are deeply connected with one
another. “Views of the nature of knowledge interact with views of the nature of
reality: what there is affects what can be known, and what we think can be known
often affects what we think exists” (Thagard, 2007, p. xi). For instance, if one
subscribes to the belief that there is a reality independent of the researcher, then
scientific inquiry should be conducted in a way that is objectively detached. This
will enable the researcher to discover “how things really are” and “how things
really work.” This in turn requires that the researcher identifies a set of method-
ologies that are capable of reflecting objective reality in a pure or relatively uncon-
taminated manner. From this perspective, questions that concern axiology
(values) fall outside the realm of legitimate scientific inquiry.
Conclusion. When we articulate our philosophical assumptions, we are articulat-

ing the set of decisions we have made prior to engaging in scientific or therapeutic
practice. These decisions involve asking and answering questions that are not
empirical but rather preanalytic in nature (e.g., What type of knowledge do we
want to accumulate and why? How will we organize and construct that system of
knowledge? What qualifies as “real or genuine evidence,” and how should it be
interpreted?). The answers to these questions form the foundation upon which
empirical work is carried out. Just as we need to lay a foundation before we can
build a stable house, so too do we need to lay down our philosophical assumptions
before we can engage in scientific activity that is consistent and coherent.
Part 2: Pepper’s Four Worldviews and Their

Relation to Clinical Psychology
Although worldviews can and have been categorized in many different ways,
Pepper’s (1942) classification scheme is useful in reflecting upon the components,
30
assumptions, and concerns that drive theory and research in different areas of
clinical and applied psychology.
The core of Pepper’s thesis is that humans are not prone to engaging in
complex, abstract thought, and they tend to rely on commonsense guides or “root
metaphors” to keep their intellectual bearings. He argued that the major, rela-
tively adequate philosophical positions can be clustered into one of four core
models (“world hypotheses”): formism, mechanism, organicism, and contextual-
ism. Each uses a different root metaphor as a kind of thumbnail guide that sug-
gests how knowledge ought to be justified or represented, how new knowledge
should be obtained, and how truth can be evaluated (for more, see Berry, 1984;
Hayes et al., 1988; Hayes, 1993).
These worldviews are autonomous (because their basic assumptions are
incommensurable) and allow content in different domains of knowledge to be
described with precision (i.e., applying a restricted set of principles to specific
events) and scope (i.e., analyses that explain a comprehensive range of events
across a variety of situations). Their truth criteria provide a way of evaluating the
validity of scientific analyses that emerge from a particular worldview. In the fol-
lowing section I consider each of these worldviews and then discuss how they set
the stage for particular kinds of clinical research and practice.
Formism
The root metaphor of formism is the recurrence of recognizable forms. An
easy way to think of formism is that it is a form of philosophy based on the action
of naming—that is, knowing how to characterize a particular event. For instance,
smartphones constitute a class or category in which many particulars are said to
“participate.” The truth or validity of an analysis is based on simple correspon-
dence: an individual member possesses characteristics that correspond to the
characteristics of the class. A brick is not a smartphone because it is not electronic
and you cannot make calls with it; a desktop computer is electronic and you can
make calls with it, but it is not a smartphone, in part, because it is not portable;
and so on. The task of scientists is to create a comprehensive set of categories or
names, and the truth or value of their actions can be determined from the exhaus-
tive nature of this categorical system. “If the system has a category for all kinds of
things, and things for all categories, then the categorical system is deemed to cor-
respond with the a priori assumed world of things and events” (Wilson, Whiteman,
& Bordieri, 2013, p. 29). When applied to psychology, formism suggests that phe-
nomena can be understood by assigning them to specific classes or types, and for
that reason some nosologies or personality theories provide good examples of
formism.
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Process-Based CBT
Mechanism
Mechanism is a more sophisticated variant of formism and arguably the posi-
tion that underpins most empirical work in contemporary psychology. Its root
metaphor is the commonsense “machine.” This approach “assumes the a priori
status of parts, but goes on to build models involving parts, relations, and forces
animating such a system” (Wilson et al., 2013, p. 29). When applied to psychology,
the purpose of science is to identify the parts and their relationships (e.g., mental
constructs, neurological connections) that mediate between input (environment)
and output (behavior), and to identify the operating conditions or forces that are
necessary and sufficient for mechanisms to successfully function (e.g., attention,
motivation, cognitive capacity, information). (Note that “mechanism” has some-
times been used within applied psychology as an epithet, meaning “robot-like” or
“unfeeling.” This is not its meaning in philosophy of science, and I don’t suggest
any negative connotations when I use the term.)
Within a mechanistic worldview, causation is contiguous: “one step in the
mechanism (e.g., a mental state) puts in motion the next step (e.g., another mental
state)” (De Houwer, Barnes-Holmes, & Barnes-Holmes, 2016; chapter 7 of this
volume, p. 122). Stated more precisely, mechanism argues that mental processes
operate under a restricted set of conditions, and these are separate from, but
co-vary with, the environmental context under which behavior is observed. Thus,
the unit of analysis for mechanisms (mental or physiological) is the component
element of the machine (e.g., a process, entity, or construct). Although some of
these elements are directly observable in principle (e.g., neurons), in psychology
they often are inferred from changes in behavior due to organismic interactions
with the environment (see Bechtel, 2008).
Note that the root metaphor of a machine applies both to the knower and
what is known. “The knower relates to the world by producing an internal copy of
it, through mechanical transformation. This epistemological stance preserves
both the knower and the known intact and basically unchanged by their relation”
(Hayes et al., 1988, p. 99). Analyses are considered “true” or “valid” when the
internal copy of reality (the hypothesized model or theory) maps onto the world
as it is. This is a more elaborated version of the correspondence-based truth crite-
rion of formism. How well a particular system reflects reality is evaluated by the
extent to which other independent knowers corroborate it through predictive
verification or falsification.
Because mechanists view complexity as being built up from parts, they tend
to be reductionistic. The goal of science is to identify the most basic units that fill
the temporal gaps between one event and another (e.g., mental representations,
past behaviors, neural activity, emotions). This is typically achieved by building
32
facsimiles of reality (internal copies) in which truth or validity is determined from

its objective correspondence with that reality (e.g., mental models). Description
and theoretical prediction constitute satisfactory forms of scientific explanation,
given that they allow one to evaluate correspondence between theory and reality.
The result (at least in psychology) is a largely hypothetico-deductive and theory-
driven research agenda, one that downplays distal factors (histories of learning)
and emphasizes behavior as the product of internal, independent causal agents or
systems.
Clinical implications. The most common extension of mechanistic thinking in

clinical psychology is the formulation of theories and models that detail the com-
ponent elements and operating conditions of the mental machine, which medi-
ates between environment and dysfunctional behavior. In either case, the source
and solution to clinical problems can be found in the elements that compose the
system: through the addition, revision, and elimination of mechanisms and/or
operating conditions, one can impact the probability of clinical outcomes. Given
a truth criteria based on the elaborated correspondence between the proposed
system and reality, the mechanist considers the predictive verification of theories
and therapies essential.
These philosophical assumptions are inherent in many cognitive and
behavioral therapies. For example, the impact of stimulus pairings or operant con-
tingencies in early behavior therapy might be explained by the formation and
revision of stimulus-response or stimulus-stimulus associations (e.g., see Foa,
Steketee, & Rothbaum, 1989). Similarly, the impact of cognitive therapy (Beck,
1993; Mahoney, 1974) might be explained by the cognitive schemas, faulty
information-processing styles, irrational cognitions, or automatic thoughts that
are believed to mediate the relationship between environmental input and behav-
ioral/emotional output. As a result of these explanations, the target of interven-
tion would be a change in the occurrence of these events, through restructuring,
reappraisal, the modification of core beliefs, and so on (e.g., Hofmann, 2011; see
chapters 21 and 22).
Organicism
The root metaphor at the core of organicism is that of the growing organism.
Organicists view organic development as beginning in one form, growing and tran-
sitioning in an expected pattern, and then ultimately culminating in another form
that was inherent in what came before. Consider, for example, the organic process
through which a seed turns into a tree. There are rules of transition between states
or phases, and stability between periods of change, but once rules are identified and
33
Process-Based CBT
explained, the states, phases, and stability are seen as part of a single coherent
process. In order to explain the present and predict the future, we must understand
the basic rules that govern development and how these rules operate across both
time and context (Reese & Overton, 1970; Super & Harkness, 2003).
Organicism is teleological. Just as a seed may be “meant to be” a tree, stages
of development make sense only by knowing where they are headed. The truth
criterion of organicism is coherence. “When a network of interrelated facts con-
verges on a conclusion, the coherence of this network renders this conclusion
‘true.’ All contradictions of understanding originate in incomplete knowledge of
the whole organic process. When the whole is known, the contradictions are
removed and the ‘organic whole…is found to have been implicit in the fragments’”
(Hayes et al., 1988, p. 100).
Organicists reject the idea of simple, linear cause-effect explanations, prefer-
ring a more synthetic (interactional) approach. They argue that a system cannot
be understood by breaking it down into its component elements. The whole is not
a combination of individual parts; rather, the whole is basic, with parts having
meaning only with regard to the whole. The identification of parts or stages is to
some degree an arbitrary exercise for the purpose of investigation, but the order of
those stages is not. For instance, “where the line is drawn marking the difference
between an infant and a toddler may be arbitrary, but that infancy precedes tod-
dlerhood is nonarbitrary and is presumed to reflect the a priori organization of
development” (Wilson et al., 2013, p. 30).
Contextualism
The root metaphor of contextualism is the ongoing “act in context.” Acts can
be anything done in and with a current and historical context and are defined by
their purpose and meaning. Contexts can “proceed outward spatially to include
all of the universe…[or] backward in time infinitely to include the remotest ante-
cedent, or forward in time to include the most delayed consequence” (Hayes &
Brownstein, 1986, p. 178). The act in context is not a description of some static
event that occurred in the past. Instead it is a purposeful activity that takes place
here and now within physical, social, and temporal contexts. Thus, in contextual-
ism (as in mechanism and organicism), relations and forces may be described.
However, the described organization of those forces and relations is not assumed
to reflect some a priori organization of the world (as is the case with formism or
mechanism) nor some progression toward an “ideal form” (as is the case with
organicism). Rather, speaking of the parts and relations is itself the action of sci-
entists who operate in and with their own contexts and for their own purposes
(Hayes, 1993). Consequently, scientific activity based on contextualistic thinking
34
(within psychology) is not concerned with descriptions of the “real world” but
rather “verbal analyses that permit basic and applied researchers, and practitio-
ners, to predict and influence the behavior of individuals and groups” (De Houwer,
Barnes-Holmes, & Barnes-Holmes; chapter 7 of this volume, p. 124).
Note that an act in context can vary from the most proximal behavioral
instance (e.g., social anxiety as one interacts with colleagues here and now) to
temporally distal and remote behavioral sequences (e.g., the impact a particular
experience two years ago has on choosing whether to attend a social gathering in
several days’ time). What brings order to this spread of possibility is the pragmatic
goal of an analyst (see Barnes-Holmes, 2000; Morris, 1988; Wilson et al., 2013).
The metric of truth is neither correspondence nor coherence with a mind-
independent reality but simply anything that facilitates successful working (this is
the same truth criterion previously mentioned in the section on constructivism,
and indeed constructivists are often contextualists).
There are, however, varieties of scientific contextualism. In order to know
what successfully works, one must know what one is working toward: there must
be a clear a priori statement of the scientist’s or practitioner’s goal or intent (Hayes,
1993). Descriptive contextualists (dramaturgists, narrative psychologists, post-
modernists, social constructionists) are focused on analyses that help them appre-
ciate the participation of history and circumstance in the whole; functional
contextualists are trying to predict and influence behavior with precision, scope,
and depth (Hayes, 1993). Because of this, contextualism is relativistic—what is
considered true differs from one scientist to another based on respective goals.
Clinical implications. Contextualism focuses the clinical researcher and practi-

tioner on the meaning and purpose of a person’s thoughts, feelings, and actions in
a given context. Humanistic psychology tends toward a descriptive contextual
istic position in which therapists seek to appreciate the wholeness of a psychologi-
cal event (Schneider, 2011). Many forms of modern cognitive and behavioral
methods, such as acceptance and commitment therapy (ACT; Hayes et al., 1999),
functional analytic psychotherapy (Kanter, Tsai, & Kohlenberg, 2010), integrative
behavioral couples therapy (Jacobson & Christensen, 1998), and behavioral acti-
vation (Jacobson, Martell, & Dimidjian, 2001), consciously adopt the core of a
functional-contextual position. Others, such as dialectical behavior therapy
(Linehan, 1993; Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006),
mindfulness-based cognitive therapy (Segal et al., 2001), and rational-emotive
behavior therapy (Ellis & Dryden, 2007), mix the contextual perspective with
elements of mechanistic thinking.
ACT can be used as a brief example to help show how contextualistic think-
ing takes the scientist or practitioner down a different pathway than mechanistic
35
Process-Based CBT
perspectives. Broadly speaking, ACT does not focus on the content of a thought,
attempt to manipulate its form or frequency, or concern itself with the extent to
which it is “real.” Instead it pays close attention to what function the thought,
feeling, or behavior has for the client in a given context. Consider the example of
a public speaker who encounters the thought I’m going to have a panic attack as she
walks toward a podium. An ACT therapist might not assume that this thought is
necessarily harmful or that it has to be eradicated or revised. Rather he might ask,
“How can you relate to this thought in a way that will foster what you want?”
The therapist adopts this approach because he views cognitions, emotions,
beliefs, and dispositions as dependent variables (actions) and not as (the ultimate)
contiguous causes of other dependent variables, such as overt behavior. In order
to predict and influence the relationship between, say, thoughts and overt behav-
ior, the therapist needs to identify the independent variables that can be directly
manipulated in order to alter that relationship, and— from the therapist’s
perspective—only contextual variables are open to direct manipulation (Hayes &
Brownstein, 1986). Mental mechanisms (e.g., associations in memory, schemas,
semantic networks, or propositions) and the hypothesized forces that bind them
are (at best) more dependent variables—they are not functional causes. That
same truth criterion (successful working) also applies to clients who are “encour-
aged to abandon any interest in the literal truth of their own thoughts or evalua-
tions…[and] instead…are encouraged to embrace a passionate and ongoing
interest in how to live according to their values” (Hayes, 2004, p. 647).
Part 3: Selection, Evaluation, and

Communication Among Worldviews
Now that I’ve discussed a number of worldviews and how they inform clinical
thinking and practice, you may be asking yourself a new set of questions about
selection, evaluation, and communication. For instance, exactly how, when, and
why did you decide to subscribe to a particular worldview, and is your belief system
any better or more useful than that of your peers? Given their fundamental differ-
ences, can proponents of one worldview ever communicate and interact with
those adopting another perspective? It is to these questions that I now turn.
Worldview Selection
People may find themselves adhering to a particular worldview for several
reasons. First, their philosophical orientation (and thus theoretical predilections)
may be partially determined by individual differences, such as temperament and
36
personality attributes (e.g., Babbage & Ronan, 2000; Johnson, Germer, Efran, &
Overton, 1988). Second, worldviews may not be consciously selected but rather
implicitly thrust upon us by the prevailing scientific, cultural, historical, and
social contexts in which we find ourselves embedded. In other words, scientists
may assimilate or inherit the philosophical framework that underpins the domi-
nant zeitgeist of their field during their training. Thus worldview selection may be
to some extent irrational (Pepper, 1942; Feyerabend, 2010; Kuhn, 1962; although
see Lakatos, 1978, for arguments centered on rational research-program selec-
tion). For instance, once prediction is implicitly adopted as a scientific aim, then
(mental) mechanistic explanations may be simpler and “commonsense.” If your
goal is to predict and influence behavior, a contextual position may seem more
valuable. Third, people can evaluate the different types of scientific outcomes
that are produced when different worldviews are adopted and effectively “vote
with their feet” (Hayes, 1993, p. 18). The popularity of worldviews seems to shift
across time, both within and between scientific communities (Kuhn, 1962).
Psychological science is no exception, with a variety of metatheoretical paradigms,
theories, and empirical issues gaining prominence at one time or another.
Worldview Evaluation
Although popular convention, personality disposition, or matters of taste may
guide the selection of any particular worldview, the standards of evaluation applied
to that worldview are specified. When we evaluate a particular product of scien-
tific activity (e.g., a finding, theory, or therapy) as being either good or satisfactory,
we are basically asking whether that activity is consistent or coherent with the
internal requirements of a worldview and with the consumers of new knowledge.
Evaluating one’s own worldview. One reason to clarify your own philosophical
assumptions is that it allows you to evaluate your own scientific activity. For
instance, if one adopts a positivist (realist) position, theories are “mirrors” that
vary in the extent to which they reflect the world “as it really is.” Evaluation and
progress therefore require that standards be applied to scientific inquiry that lead
to the development of mirrors that best reflect reality. Postpositivists (critical real-
ists) take a similar (if qualified) position, wherein researchers develop theories
that are akin to dirty mirrors contaminated by error and bias. Standards of evalu-
ation and progress involve polishing theoretical mirrors so as to remove distortion
in order to represent reality as closely as possible. A researcher can best test a
knowledge claim of this kind with a hypothetico-deductive model of theory devel-
opment, in which highly precise predictions are extended to relatively unexplored
domains (see Bechtel, 2008; Gawronski & Bodenhausen, 2015).
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Process-Based CBT
Theory testing looks quite different if one takes a contextualistic or construc-

tivist stance. In these worldviews, theories are merely tools with which to achieve
some end. Consider how a commonsense tool, say a hammer, could be evaluated:
“A hammer is a good ‘hammer’ if it allows the carpenter to drive a nail. It would
not make sense to say that the hammer does so because it accurately refers to the
nail or reflects the nail” (Wilson et al., 2013, p. 30). Similarly, a theory is consid-
ered a good theory if it allows the scientist to achieve some desired outcome. In
this case, theory evaluation involves determining the consistency with which
models or theories can be shown to lead to useful interventions across a range of
situations (e.g., see Hayes, Barnes-Holmes, & Wilson, 2012; Long, 2013).
Evaluating the worldview of others. When evaluating research programs based

on a worldview other than your own, it is inherently dogmatic to apply criteria
that emerge from your own worldview. A great deal of useless and counterproduc-
tive energy has been spent doing so in both basic and applied psychological
science. For instance, researchers and therapists adhering to a functional-
contextual perspective might question why their colleagues are so preoccupied
with pieces of the mental machinery and their operating conditions, when doing
so may depreciate the role that histories of learning and contextual variables play
in how thoughts lead to other actions. Mechanists may counter that contextual-
ists are not interested in scientific understanding—they are mere “technicians” or
“problem solvers” who manipulate the environment in order to produce changes
in behavior without any appreciation of the mechanisms that mediate those
changes.
What should be clear, however, is that these arguments are pseudocon-
flicts—an attempt by proponents of one worldview to position their own philo-
sophical assumptions (and thus scientific goals and values) as ultimately right and
the worldview of others as wrong. Yet philosophical assumptions cannot be proven
to be right or wrong because they are not the result of evidence—they define
what is to be considered “evidence.” The standards developed within a given
worldview can be applied only to the products that emerge from that approach (in
much the same way that the rules that make sense within one sport (soccer)
cannot be used to govern the activity of another (say, basketball). Furthermore,
no worldview is strengthened by showing the weaknesses of other positions.
There are four legitimate forms of evaluation. One is to improve your own
scientific products as measured against the criteria appropriate to your approach.
A second is less obvious but professionally helpful and collegial: enter into the
assumptions of colleagues that differ from your own and then help them improve
the scientific products as measured against the criteria that are appropriate to
those assumptions. A third is to clearly articulate the assumptions and purposes
38
that underpin your scientific activity and note (nonevaluatively) how they differ
from others. For instance, you can describe the root metaphor and truth criterion
that you’ve adopted, and how your analyses are carried out from this perspective,
without insisting that others with different assumptions do the same. A fourth
approach is to note the goals and uses of science by consumers (e.g., government
funders, clients) and to objectively assess whether research programs serve those
ends.
Communication and Collaboration Among

Proponents of Different Worldviews
In light of the above, you might wonder if it’s possible for adherents of one
worldview to communicate and collaborate with those from another without sac-
rificing their respective goals and values in the process. The received wisdom in
psychology is that communication across worldviews is not possible. A concrete
example is the way researchers use the same words to refer to different concepts
(e.g., “cognition” means very different things for mental- mechanistic and
functional-contextual researchers; see chapter 7) or use different words to refer to
a similar idea (e.g., “attentional allocation” or “stimulus discrimination”). The
most common result of these difficulties appears to be either fights over perceived
scientific legitimacy or an ignoring of the fruits of colleagues’ labors.
There is a radically different way to think of this situation, however, and it
helps explain why training in philosophy of science is now expected of practitio-
ners. If scientific goals of different worldviews are orthogonal, it also means they
cannot be in direct conflict with one another. Thus, there is no reason why devel-
opments within one tradition cannot be used to further the scientific agenda of
the other. This book is organized around that core idea. Process-based therapy
can be linked to evidence from different traditions. By appreciating legitimate
differences, the different wings or waves of evidence-based therapy can comple-
ment each other.
One way that individuals from different traditions can achieve scientific
cooperation is by adopting a metatheoretical perspective known as the functional-
cognitive (FC) framework (see chapter 7 for a detailed treatment). According to
this perspective, psychological science can be conducted at two different but sup-
portive levels of analysis: a functional level that aims to explain behavior in terms
of elements in the environment, and a cognitive level that aims to understand the
mental mechanisms by which elements in the environment influence behavior.
The FC framework does not interfere with the individual researcher’s goals, nor
does it pass judgment on those goals or the reasons behind them. Instead, it seeks
39
Process-Based CBT
a mutually supportive interaction. Research at the functional (contextual) level,

for example, can provide knowledge about the environmental determinants of
behavior, which can also be used to drive mental research and/or to constrain
mental theorizing. So long as each approach remains committed to its form of
explanation, knowledge gained at one level can be used to advance progress at the
other (De Houwer, 2011). This metatheoretical framework has yielded benefits in
several areas of research (for a recent review see Hughes, De Houwer, & Perugini,
2016), and there appears to be no reason not to extend it to clinical psychology
and such issues as the differences among wings of behavioral and cognitive therapy
(De Houwer, Barnes-Holmes, & Barnes-Holmes, 2016; see also chapter 7 of this
volume).
Conclusion
The main goal of this chapter was to introduce the topic of philosophy of science
as it applies to clinical and applied psychology. Philosophical assumptions silently
shape and guide our scientific activity and therapeutic practice. “Assumptions or
‘world-views’ are like the place one stands. What one sees and does is greatly
determined by the place from which one views. In this way, assumptions are
neither true nor false, but rather provide different views of different landscapes”
(Ciarrochi, Robb, & Godsell, 2005, p. 81). Appreciating the role of philosophical
assumptions tempers and guides collegial interaction within the field and is an
important context for research evaluation, communication, and collaboration.
Philosophical assumptions make a difference, whether in the laboratory or the
therapy room.
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43
CHAPTER 3
Science in Practice
Kelly Koerner, PhD

Evidence-Based Practice Institute
Evidence-based practice (EBP) originated in medicine to prevent errors and to

improve health care outcomes (Sackett, Rosenberg, Gray, Haynes, & Richardson,
1996). In psychology EBP is defined as “the integration of the best available
research with clinical expertise in the context of patient characteristics, culture,
and preferences” (American Psychological Association Presidential Task Force on
Evidence-Based Practice, 2006). In an evidence- based approach to decision
making (Spring, 2007a, 2007b), the practitioner should:
1. Ask important questions about the care of individuals, communities, or

populations.
2. Acquire the best available evidence regarding the question.
3. Critically appraise the evidence for validity and applicability to the

problem at hand.
4. Apply the evidence by engaging in collaborative decision making regard-

ing health with the affected individual(s) and/or group(s). (Appropriate
decision making integrates the context, values, and preferences of the
care recipient, as well as available resources, including professional
expertise.)
5. Assess the outcome and disseminate the results.
EBP seems to be a straightforward process: get the relevant evidence, discuss

it with the client, and then carry out the best practice. Yet doing so requires over-
coming two sets of significant challenges: (1) finding and appraising evidence
relevant to many clinical decisions is difficult, and (2) clinical judgment is notori-
ously fallible.
Process-Based CBT
Challenges with Using the Evidence Base

to Inform Clinical Decisions
To adopt an evidence-based approach to treat a client’s specific problems, practi-
tioners should prepare by reviewing relevant research literature to identify the
most effective assessment and treatment options and evaluate evidence claims as
scientific knowledge accumulates and evolves. Yet doing so can be difficult or
impossible.
Research evidence comes to us more easily than ever before: passively through
the day-to-day use of social media or actively when we use a search engine for a
specific client-related question. In both cases, however, it’s not the quality or
merits of the research evidence that drive what we see. Regularly cited articles
become ever more likely to be cited, creating an impression of greater quality and
masking other evidence (the Matthew effect; see Merton, 1968). Search engines
grant higher page positions based on algorithms unrelated to evidence quality.
Consequently, for a balanced evaluation of evidence, practitioners must
increasingly rely on experts to distill scientific findings into rigorously curated,
aggregated formats, such as practice guidelines, lists of empirically supported
treatments, evidence-based procedure registries, and the like. Expert aggregations
use an evidentiary hierarchy: meta-analyses and other systematic reviews of ran-
domized controlled trials (RCTs) at the top; followed by individual RCTs; fol-
lowed by weaker forms of evidence, such as nonrandomized trials, observational
studies, case series reports, and qualitative research.
Not only is this fixed evidentiary hierarchy itself controversial (Tucker &
Roth, 2006), the existing literature provides little evidence to guide the selection
of conditional plans that have a high chance of success: If a client presents marker
A, will intervention B predictably and consistently produce change C? For
example, say a late-twenties professionally employed Latina woman seeks treat-
ment for depression. Based on the evidence, behavioral activation could be a
good choice (Collado, Calderón, MacPherson, & Lejuez, 2016; Kanter et al.,
2015). However, if in addition to depression the client has common co-occurring
problems such as insomnia or marital conflict, the guidance is either absent or
confusing: some evidence guides the practitioner to treat insomnia and depres-
sion concurrently (Manber et al., 2008; Stepanksi & Rybarczyk, 2006), while
other evidence supports combining depression treatment and marital therapy to
help with depression and marital satisfaction (Jacobson, Dobson, Fruzzetti,
Schmaling, & Salusky, 1991). If additional common problems are added, such as
problem drinking or child behavior problems in the home, the literature provides
little or no guidance. Evidence to directly inform decision making for even
46
Science in Pr actice
common branches, such as those regarding sequencing versus combining treat-

ments, is scarce.
In part, the lack of data to inform clinical decisions is an unavoidable conse-
quence of research challenges. Science takes time. The study of psychopathology
and psychotherapeutic change is complex. The practitioner’s need for nuanced
evidence may always outstrip what is practically possible in even the most practice-
focused research agenda. But in important ways, the lack of evidence to guide
routine clinical decisions is due to more pernicious problems with the methods
used to conduct psychotherapy research.
For historical reasons, the research methods used to study behavioral inter-
ventions borrowed heavily from methods and metaphors used to develop and test
pharmaceuticals. In this predominant psychotherapy-as-technology stage model,
stage I consists of basic science being translated into clinical applications. Pilot
testing and feasibility trials begin on new and untested treatments, and treatment
manuals, training programs, and adherence and competence measures are devel-
oped. In stage II, RCTs that emphasize internal validity evaluate the efficacy of
promising treatments. In stage III, efficacious treatments are subjected to effec-
tiveness trials and are evaluated with regard to their external validity and trans-
portability to community settings (Rounsaville, Carroll, & Onken, 2001).
Important updates have reinvigorated the stage model (Onken, Carroll, Shoham,
Cuthbert, & Riddle, 2014), but methodological choices guided by the model have
led to unintended consequences for the evidence base that interfere with its utility
in guiding routine clinical decisions.
A core problem is that the independent variable to be studied and delivered
in psychotherapy has come to be defined almost solely as the unit of the treatment
manual, and the problem focus at the level of the psychiatric syndrome. The
treatment manual codifies clinical procedures and their order into a protocol to
be standardly repeated across therapists and clients by disorder. Manuals that
specify protocols for treating depression, insomnia, problem drinking, couple dis-
tress, and parenting skills deficits, for example, could be relevant to the case
example presented earlier, but each manualized protocol comprises many compo-
nent strategies. Psychoeducation, self- monitoring, motivation enhancement,
problem solving, activation assignments, values clarification, contingency man-
agement, shaping, self-management, and so on appear in nearly every manual.
Most component strategies are not unique to a single manual but instead are
common and duplicated across manuals. Specific protocols may vary in how they
emphasize or coordinate these component elements (Chorpita & Daleiden,
2010)—the way procedures are chosen, repeated, or selectively applied, or their
delivery format—even if the basic ingredients remain the same. Because research-
ers and therapists predominantly consider manuals as the unit of analysis, they
47
Process-Based CBT
ignore the fact that various manuals contain mostly the same ingredients. Each
manual is treated as a distinct intervention with its own siloed research base
(Chorpita, Daleiden, & Weisz, 2005; Rotheram-Borus, Swendeman, & Chorpita,
2012).
Strictly privileging manuals as the unit of intervention and analysis by disor-
der leads to unintended problems. Any change made to a manualized protocol
could be a substantive departure. Even making a modification to better fit clients’
needs or setting constraints may wipe out the relevance of existing evidence. For
the researcher, this “ever-expanding list of multi-component manuals designed to
treat a dizzying array of topographically defined syndromes and sub-syndromes
creates a factorial research problem that is scientifically impossible to mount…
[and] makes it increasingly difficult to teach what is known or to focus on what is
essential” (Hayes, Luoma, Bond, Masuda, & Lillis, 2006, p. 2). For the practitio-
ner, the choice becomes to either follow manuals to the T regardless of setting or
client presentations and preferences, or accept responsibility for not knowing
what outcomes can be expected if tailored treatment deviates from the manual.
Packaging knowledge and science at the unit of a “manual for a disorder”
emphasizes differences among manuals even if there are overlapping common
components. Researchers are incentivized for innovation, but as reimbursement
becomes contingent on delivering evidence-based protocols, practitioners become
incentivized to claim they are doing treatments with fidelity whether they are or
not. Treatment developers then face pressure to develop quality control methods
to protect client access to the bona fide version of the treatment, leading to pro-
tective steps, such as proprietary trademarking or therapist certification. Such
steps then align the professional identities and allegiances of researchers and prac-
titioners with particular branded protocols rather than with effective components
linked to client need.
The rationale for rigid adherence to specific manuals is that the greater the
therapist’s adherence and competence in delivering the standardized, validated
protocol, the more likely it is that clients will receive the treatment’s active ingre-
dients and thereby obtain the desired outcomes. If this assumption is true, then
adherence and competence should be powerful predictors of outcome, and larger
packages and protocols should in general show unique, theory-related curative
ingredients.
The available research evidence only weakly supports this assumption. With
some exceptions, researchers don’t consistently find correlations between adher-
ence or competence and treatment outcome (Branson, Shafran, & Myles, 2015;
Webb, DeRubeis, & Barber, 2010). And while there are many successful theory-
consistent meditational studies, there are also many large, well-designed studies
that have failed to find unique, distinct, theory-related processes of change
48
(Morgenstern & McKay, 2007). If more focus was made on specific components
and procedures, a focus on change processes could well be more successful, but
using large manuals as the unit of analysis interferes with that possibility.
Adopting concepts and methods from pharmacotherapy research and devel-
opment has produced other problems. The dose-response idea that a dosage of
active ingredients produces uniform and linear patterns of client change does not
fit the large individual differences in client responsivity observed in psychother-
apy research. Clients differ in whether they are in fact absorbing the material and
achieving desired changes in cognitions, emotions, and skills and whether these
changes in turn lead to desired outcomes. As a result, large individual differences
in client response occur even in treatments that have been standardized and with
therapists who show high adherence to the treatment manual (Morgenstern &
McKay, 2007).
Similarly, therapists aren’t uniform in the same ways that pills are uniform.
Nonspecific factors that are common across protocols, such as therapeutic alli-
ance, have been viewed as being “akin to the binding on a pill, i.e., a minimum
level of engagement is needed between therapist and patient in order to provide
an avenue to transmit the specific curative elements of the approach” (Morgenstern
& McKay, 2007, p. 102). Instead, therapists show significant variability rather
than homogeneity (Laska, Smith, Wislocki, Minami, & Wampold, 2013), which
may impact outcomes in specific ways.
To illustrate, consider work by Bedics, Atkins, Comtois, and Linehan (2012a,
2012b). They studied the relationship between therapeutic alliance and nonsui-
cidal self-injury in treatment delivered by expert behavioral and nonbehavioral
therapists (2012a). Overall ratings of the therapeutic relationship did not predict
reduced nonsuicidal self-injury. Instead, reductions were associated with the cli-
ent’s perception that the therapist blended specific aspects—affirming, control-
ling, and protecting—of the relationship. In a companion study (2012b), they
found that among clients with expert nonbehavioral therapists, higher perceived
levels of therapist affirmation were associated with increased nonsuicidal self-
injury. They speculate that the affirmations of nonbehavioral therapists might
have inadvertently been timed to reinforce nonsuicidal self-injury, whereas behav-
ior therapists contingently provided warmth and autonomy for improvement.
These findings illustrate the kinds of interplay between specific and nonspecific
factors that may impact outcome. Treatment effects of even carefully standardized
treatments aren’t uniform or homogeneous, and research methods that force over-
simplified understandings may limit scientific advancement.
Finally, social processes drive the crucial factors related to an EBP’s reach,
adoption, implementation, and sustainability at the organizational level (Glasgow,
Vogt, & Boles, 1999). Historically, the stages of the psychotherapy-as-technology
49
Process-Based CBT
model move sequentially from efficacy trials to effectiveness evaluations, and only
then to dissemination and implementation research. As a result, the research on
crucial factors that influence external validity, clinical utility, and the interven-
tion’s reach, adoption, implementation, and sustainability in routine settings is
conducted far too late in the development process (Glasgow et al., 1999). Little
evidence is available to guide decision makers who face setting constraints about
what they can and cannot change as they implement an EBP.
The Challenges of Relying on Clinical Judgment

Evidence-based practice, by definition, includes clinical judgment, but gaps in the
evidence mean that many clinical decisions are based solely on clinical judgment
with little data to inform them. Unfortunately there are known weaknesses of
clinical judgment.
Daniel Kahneman’s book Thinking, Fast and Slow (2011) has popularized our
understanding of these weaknesses. According to Kahneman’s dual processing
theory, we have two modes of processing information: system 1, a fast, associative,
low-effort mode that uses heuristic shortcuts to simplify information and reach
good-enough solutions, and system 2, a slower rule-based mode that relies on
high-effort systematic reasoning.
The fast and frugal system 1 heuristics that help us quickly simplify complex
situations leave us prone to a multitude of perception and reasoning biases and
errors. Kahneman conceptualizes the two systems as hierarchical and discrete,
and he posits that the more rational, conscious system 2 can constrain the irratio-
nal, unconscious system 1 to save us from biases and errors. However, experimen-
tal data show that these systems are integrated, not discrete or hierarchical, with
both prone to “motivated reasoning” (Kunda, 1990; Kahan, 2012, 2013a). If quick,
impressionistic thinking doesn’t yield the answer we expect or want, we are prone
to use our slower reasoning skills to fend off disconfirming evidence and seek data
that fit our motivations rather than to reconsider our position (Kahan, 2013b).
In some professions, the work environment itself can correct these problems
with judgment because work routines calibrate the unconscious processes of
system 1 and train them to select suspected patterns for the attention of system 2’s
deliberate analysis. Kahneman and Klein (2009) give the example of experienced
fire commanders and nurses in neonatal intensive care units who, over years of
observing, studying, and debriefing, tacitly learn to detect cues that indicate subtle
and complex patterns related to outcomes, such as signs that a building will col-
lapse or an infant will develop an infection. The cues in their work environments
signal the probable relationships among causes and outcomes of behavior (valid
50
cues). In such high-validity or “kind” environments, there are stable relationships

between objectively identifiable cues and subsequent events, or between cues and
the outcomes of possible actions. Standard methods, clear feedback, and direct
consequences for error make it possible to tacitly learn the rules of these environ-
ments. Hunches based on invalid cues are likely to be detected and assessed for
error. Pattern recognition improves. According to Kahneman and Klein (2009),
we can develop excellent, expert decision-making abilities, but only when two
conditions are met:
1. The environment itself is characterized by stable relationships between

objectively identifiable cues and subsequent events or between cues and
the outcomes of possible actions (i.e., a high-validity environment).
2. There are opportunities to learn the rules of the environment.
In contrast, the environments in which most psychotherapy is practiced are

low-validity or “wicked” environments that make tacit learning difficult (Hogarth,
2001). Cues are dynamic rather than static, predictability of outcomes is poor, and
feedback is delayed, sparse, and ambiguous. Psychotherapy practice environments
lack standard methods, clear feedback, and direct consequences and therefore
provide few opportunities to learn the rules about the relation between clinical
judgment, interventions, and outcomes. As a result, the tacit learning and devel-
opment of intuitive expertise is blocked, which is a recipe for overconfidence
(Kahneman & Klein, 2009). Within such low-validity environments, clinical
judgment performs more poorly than linear algorithms based on statistical analy-
sis. Even though often wrong, algorithms maintain above-chance accuracy by
detecting and using weakly valid cues consistently, which accounts for much of an
algorithm’s advantage over people (Karelaia & Hogarth, 2008). Without struc-
tured routines, heuristic biases outside of our awareness function like an auto-
matic spotlight, unconsciously simplifying complex situations. Perception,
attention, and problem solving are caught by a subset of the elements right in
front of us. In particular, without the right conditions we are likely to fall prey to
the motivated reasoning and predictable biases defined by Heath and Heath
(2013):
• Narrow framing—binary do/don’t do rather than “What are the ways I

could make X better?”
• Confirmation bias—we pretend we want “truth,” but all we want is

reassurance.
• Short-term emotion—we churn but the facts don’t change.
51
Process-Based CBT
• Overconfidence—we think we know more about how things in the future

will unfold than we do.
Disciplined Improvisation: Create Kind

Environments with Heuristic Frameworks
What may be needed is to create the kind environments Kahneman and Klein
(2009) and Hogarth (2001) describe: improved conditions in routine practice
settings that support learning the relationship between clinical judgment, inter-
ventions, and outcomes. By doing so, practitioners can engage in disciplined
improvisation as applied scientists, thereby improving the probability of good
client outcomes. This requires practitioners to have not only functional scientific
literacy but also structured routines that correct for the most common problems
with clinical judgment. “Functional scientific literacy” means specialized knowl-
edge related to probability and chance; the tools to think scientifically, and the
propensity to do so; the tendency to exhaustively examine possibilities; the
tendency to avoid my-side thinking; knowledge of some rules of formal and
informal reasoning; and good argument-evaluation skills (Stanovich, West, &
Toplak, 2011). This “mindware” is typically haphazardly acquired in professional
training.
The rest of this chapter details a short set of structured routines the practitio-
ner can use to correct for the most common problems with clinical judgment and
thereby better calibrate the decision-making process and make it possible to do
meaningful EBP. In general, each proposed routine helps to generate valid cues in
order to detect and learn about stable relationships between objectively identifi-
able cues and subsequent events, or between cues and the outcomes of possible
actions.
Many of the routines involve using a heuristic in a deliberate, structured work
routine. Instead of an unconscious spotlight, the heuristic works like a manually
controlled spotlight (Heath & Heath, 2013) or a checklist that improves perfor-
mance (Gawande, 2010). Heuristics, when used deliberately, offer general strate-
gies about how to find an answer or produce a solution in a reasonable time frame
that is “good enough” for solving the problem at hand. They help the practitioner
find the sweet spot of optimality, completeness, accuracy, precision, and execution
time. The following list of routine practices, easily done in a typical workflow,
suggests ways to standardize methods and obtain clear feedback that increase the
opportunities to learn the rules about the relation between clinical judgment,
interventions, and outcomes.
52
Standardize Key Work Routines

Consider these three steps to standardize key work routines in order to trans-
form a wicked environment into a kinder one that is disciplined enough to help
you better detect valid cues and maximize your ability to learn from them.
1. USE PROGRESS MONITORING AND OTHER

ASSESSMENT METHODS
Monitoring progress—regularly collecting data on the client’s functioning,
quality of life, and change regarding problems and symptoms—is the most impor-
tant step in creating an environment with valid cues that make learning possible.
Whether this step is called progress monitoring, client- reported outcomes,
measurement-based care, or practice-based evidence, it has been demonstrated
that tracking client change prevents dropout and treatment failure, reduces treat-
ment length, and improves outcomes (e.g., Carlier et al., 2012; Goodman, McKay,
& DePhilippis, 2013).
Where possible, use measures with standardized norms. When idiographic
assessment is needed (i.e., comparing people with themselves), consider tools such
as goal attainment scaling (Kiresuk, Smith, & Cardillo, 2014) or a “top problems”
approach, in which clients identify the top three problems that matter to them
and rate the severity of the problems on a scale of 0 to 10 weekly (Weisz et al.,
2011). Further, consider standardizing any idiographic functional assessment used.
Such standard assessment heuristics (if target problem is X, then use assessment
method Y) may increase the speed and consistency with which problems are
defined, providing a counter to the limitations of clinical judgment.
In particular, adopt heuristic rules about how to use progress-monitoring data
to guide decisions in which bias is likely to be highest. For example, consider a
routine such as requiring a change in the treatment plan every ten to twelve
weeks if the client has not had at least a 50 percent improvement in symptoms
using a validated measure (Unützer & Park, 2012).
More generally, routinely obtain high-quality standardized data to inform
decisions. Consider creating invariant routines using evidence-based assessment
methods, such as broad symptom rating scales, to identify presenting problems
and maintaining factors; followed by more in-depth, specific rating scales; and
then standardized clinical interviews (see Christon, McLeod, & Jensen-Doss,
2015, for more on evidence-based assessment). The key is to build routines that
stay more or less stable and standardized to reduce method variability and thereby
allow for the detection of valid signals identifying relationships between clinical
judgment, interventions, and client outcome.
53
Process-Based CBT
2. CONSIDER EXISTING EBPS FOR THE CLIENT’S

TOP PROBLEM FIRST
Whenever possible, begin with a standardized treatment protocol for the most
important problem. Beginning with a standard protocol offers many advantages.
First, treating the most important problem may resolve others. Second, a stan-
dardized protocol gives you a benchmark against which to evaluate outcomes.
Finally, following an evidence-based protocol allows you to limit your own incon-
sistency and my-side bias.
Again, although the evidence for protocols isn’t strong enough to treat them
as algorithms (step-by-step instructions that predictably and reliably yield the
correct answer every time), protocols do offer heuristics that usefully simplify
complex situations. Therapy protocols can be thought of as means-ends analyses.
Means-ends analysis is a heuristic in which the ends are defined, and means to
those ends are identified. If no workable means can be found, then the problem is
broken into a hierarchy of subproblems, which may in turn be further broken into
smaller subproblems until means are found to solve the problem.
The structured if-then guidelines that protocols provide help simplify complex
clinical situations into a series of systematic prompts to think or act. Some proto-
cols specify what problems the therapist should analyze and how to analyze them,
and they provide further heuristics on how to combine component treatment
strategies based on the nature and severity of a client’s problems. In these ways,
structuring clinical intervention with a protocol can help you detect valid cues
and create a structured environment to promote learning.
Another useful standard routine is to systematically consider alternative, rel-
evant treatment protocols as part of shared decision-making and consent-to-
treatment conversations with clients. The more a practitioner clearly and
deliberately considers alternative courses of action (Heath & Heath, 2013) and
creates structured if-then tests, the more such feedback loops can help the practi-
tioner detect whether the expected outcome happened (or didn’t) and the more
learnable the environment becomes. The PICO acronym is a way to frame a clini-
cal question for a literature search that works well for shared decision making. P
stands for “patient,” “problem,” or “population”; I for “intervention”; C for “com-
parison,” “control,” or “comparator”; and O for “outcomes” (Huang, Lin, &
Demner-Fushman, 2006).
54
Child DEPRESSION
behavior
problems
Problem
drinking
Couple
conflict Insomnia
Figure 1. Visual diagram conceptualizing the relationship among client

problems
For example, figure 1 returns to the earlier client example and shows the
visual diagram the client and therapist made to capture the relationship among
the client’s problems. The client was most troubled by low mood, low energy,
fatigue, difficulty concentrating, and feelings of intense guilt and hopelessness
scoring in the severe range on the depression scale of the Depression Anxiety
Stress Scales (Lovibond & Lovibond, 1995). In her view, her children’s behavior
problems, and the conflicts she and her husband had over parenting, made each
problem worse and greatly impacted her mood, and sometimes her sleep. She
turned to alcohol to escape painful emotions. Using PICO, the therapist can
explain treatment options and likely outcomes for each of these problems (see
table 1 for details).
55
Process-Based CBT
Table 1. Modular component treatment plan

Patient, Intervention Comparison and
Problem, Outcome
Population
#1 Depression Behavioral activation (BA): Other options to consider:

• 50–60% recover • Natural recovery
(Dimidjian et al., 2006) • Antidepressant medication
• Try BA for 8 to 10 sessions, (ADM): ~1/3 respond, 1/3
then reevaluate and partial response, relapse rate
consider alternative high when discontinuing
treatment if there is less • Combine ADM and
than 50% change in psychotherapy: ~53% report
depression on the symptom reduction
Depression Anxiety Stress
Scales. • Interpersonal therapy and
other active treatment: ~50%
symptom reduction
• Behavioral couples therapy
(Jacobson et al., 1991): 87%
recover from depression;
couples’ distress also reduced
#2 Problem Brief intervention for problem Reduces amount and frequency

drinking drinking; one of the first for many; less studied with
activation assignments of BA women. Self-help or CBT, if brief,
(O’Donnell et al., 2014) doesn’t produce desired change
on Alcohol Use Disorders
Identification Test (AUDIT).
#3 Insomnia CBT for insomnia (CBT-I); CBT-I over medications;

sleep log one of the first effectively improving insomnia
activation assignments of BA may reduce other problems,
especially depression.
#3 P
arenting for Self-help: Review The If self-help doesn’t achieve
child behavior Incredible Years: A Trouble- enough gains, consider an
problems Shooting Guide for Parents of evidence-based parent-training
Children Aged 2–8 (Webster- program.
Stratton, 2006) as an
activation assignment.
#3 Couples Devise activation assignments If individual changes fail to

conflict to strengthen conflict produce sufficient desired
resolution and marital changes, consider couples
satisfaction. counseling.
56
3. USE EXPLICIT CASE FORMULATION FOR

HYPOTHESIS TESTING
When a standard treatment isn’t available or doesn’t yield desired results,
practitioners use case formulation to tailor interventions, based on the assump-
tion that tailored intervention will outperform the imperfect fit of standardized
protocols for the individual. Unfortunately, case formulation has a meager evi-
dence base. Kuyken’s thorough and fair-minded review concludes that the evi-
dence for case formulation’s
reliability is “supportive of descriptive but not inferential hypotheses,”
validity is “very limited but promising,” and
acceptability and usefulness are “mixed” (2006, p. 31).
Kuyken concludes, “There is no compelling evidence that [cognitive behav-

ioral therapy] CBT formulation enhances therapy processes or outcomes” (p. 31).
While there is a lack of strong evidence to suggest that tailored interventions
based on case formulations are superior, when used systematically case formula-
tion can serve as a disciplined method to apply the scientific method to clinical
work (Persons, 2008). When the therapist must go beyond existing protocols,
purposefully specifying dependent and independent variables, combined with
progress monitoring, can create conditions for the therapist to learn the stable
relationships between judgment, interventions, and outcome; and this method
can counter problems with bias and unconsciously applied heuristics. Persons
(2008) and Padesky, Kuyken, and Dudley (2011) have articulated systematic
approaches to case formulation. At a minimum, the heuristic to apply with case
formulation is to specify the treatment targets (dependent variables) and robust
change processes (independent variables).
Use a Treatment Target Hierarchy Informed

by Science
A treatment target hierarchy provides if-then guidelines that prescribe what
to treat when. The target hierarchy constrains therapist variability and thereby
makes it more likely that the most essential problems are addressed first, as a
checklist does in an emergency room (Gawande, 2010). For example, Linehan
(1999) has argued for organizing treatment targets into stages of treatment based
on the severity of disorders. In pretreatment, her model directs the therapist to
target maximizing initial motivation and commitment to treatment, thereby
57
Process-Based CBT
increasing engagement, and research (Norcross, 2002) supports this common

factor. When behavioral dyscontrol is predominant, the therapist is to prioritize
target behaviors in a commonsense way by their severity: life-threatening behav-
iors first, followed by therapy- interfering behavior, quality- of-
life-
interfering
behavior, and improvement of skills.
Defined stages with target hierarchies provide a process to organize the alloca-
tion of session time, aiding the therapist’s ability to think consistently and coher-
ently; sort the relevant from irrelevant; and manage cognitive load. As discussed
earlier, these types of checklists or decision-support tools are exactly what humans
need in order to detect and respond consistently to valid cues. Treatment target
hierarchies may be particularly helpful or needed when a client has multiple dis-
orders and multiple crises that make it difficult to intervene consistently.
Using a treatment target hierarchy may also have effects, because the specific
targeted content produces client change. For example, it appears that directly tar-
geting suicidal behavior as a problem in itself (rather than seeing it as a sign or
symptom that will resolve when the underlying disorder is treated) is associated
with better outcomes (Comtois & Linehan, 2006). Treatment target hierarchies
provide a practice-friendly way to consolidate scientific knowledge.
A target hierarchy can be constructed from disorder-specific processes or
transdiagnostic processes drawn from psychopathology or treatment research. For
example, in adapting disorder-specific targets to treat substance abuse, McMain,
Sayrs, Dimeff, and Linehan (2007) didn’t target stopping the use of illegal drugs
and the abuse of prescribed drugs alone; they also targeted the physical and psy-
chological discomfort associated with withdrawal and the urges to use, because
withdrawal symptoms, urge intensity from the previous day, duration of urge, and
urge intensity upon awakening predict relapse.
Additionally or alternatively, targets can be transdiagnostic (i.e., fundamental
processes that contribute to or maintain disorders across what current diagnostic
nomenclature label as distinct). Mansell, Harvey, Watkins, and Shafran (2009)
categorize four views on transdiagnostic processes:
1. Universal multiple processes maintain all or the majority of psycho-

logical disorders. For example, processes include problematic self-focused
attention, explicit memory bias, interpretational biases, and safety behav-
iors (e.g., Harvey, Watkins, Mansell, & Shafran, 2004).
2. A range of cognitive and behavioral processes maintain a limited

range of disorders, but one that is wider than traditional disorder-
specific models. For example, researchers propose that common pro-
cesses of maladaptive cognitive appraisals, poor emotion regulation,
58
emotional avoidance, and emotionally driven behavior are related to

anxiety and depression (Barlow, Allen, & Choate, 2004) or clinical per-
fectionism, core low self-esteem, mood intolerance, and interpersonal dif-
ficulties with eating disorder (Fairburn, Cooper, & Shafran, 2003).
3. Symptom or psychological phenomena themselves, rather than diag-

nostic categories or labels, should be targeted. For example, rather than
thinking of bipolar disorder and schizophrenia as distinct entities,
Reininghaus, Priebe, and Bentall (2013) argue that the data show not
only a superordinate psychosis syndrome, but also five independent
symptom dimensions: positive symptoms (hallucinations and delusions),
negative symptoms (social withdrawal and the inability to experience
pleasure), cognitive disorganization, depression, and mania. These dimen-
sions can be treated as targets.
4. A universal, single process is largely responsible for the maintenance

of psychological distress across all or the majority of psychological
disorders. For example, Watkins (2008) proposes the importance of
repetitive thinking: the process of thinking attentively, repetitively, or fre-
quently about oneself or one’s world. Hayes and colleagues (2006, p. 6)
propose the importance of psychological inflexibility: the way “language
and cognition interact with direct contingencies to produce an inability
to persist or change behavior in the service of long-term valued ends.”
Link Targets to Robust Change Processes

Finally, when disciplined improvisation is needed because a client’s problems
don’t match well with an established protocol, or they have failed to respond to an
established protocol, try modular components of evidence- based protocols.
Chorpita and colleagues (e.g., Chorpita & Daleiden, 2010; Chorpita et al., 2005)
have led the effort to create a standardized lexicon of interventions to define the
discrete therapy technique or strategy that can serve as an independent variable
rather than use the treatment manual as the unit of analysis. In the chapters in
section 3 of this book, and in the works of others (e.g., Roth & Pilling, 2008),
components of evidence-based protocols are packaged into self-contained modules
that contain all the knowledge and competencies needed to deliver a particular
intervention.
Such modular approaches may prove to be more scientifically useful and prac-
tice oriented than relying on manuals as the unit of analysis. They remove dupli-
cation due to overspecification and could offer a way to reliably aggregate findings
59
Process-Based CBT
across studies and distill prescriptive heuristics (Chorpita & Daleiden, 2010).
Rotheram- Borus and colleagues (2012) have suggested that reengineering
evidence-based therapeutic and preventive-intervention programs based on their
most robust features will make it simpler and less expensive to meet the needs of
the majority of people, making effective help more accessible, scalable, replicable,
and sustainable.
Few prescriptive heuristics are available to guide the matching of component
interventions to targets. Further, because available data have yet to demonstrate
the unequivocal superiority of the common factors model or psychotherapy-as-
technology model, perhaps the best path for practitioners is to be informed by
both models.
According to the common factors model, five ingredients produce change.
The practitioner should create an (1) emotionally charged bond between the ther-
apist and the client and a (2) confiding, healing setting in which therapy can take
place; provide a (3) psychologically derived and culturally embedded explanation
for emotional distress that is (4) adaptive (i.e., provides viable and believable
options for overcoming specific difficulties) and accepted by the client; and engage
in a (5) set of procedures or rituals that lead the client to enact something that is
positive, helpful, or adaptive (Laska et al., 2013). From this common factors view-
point, any therapy that contains all five of these ingredients will be efficacious for
most disorders.
From a cognitive behavioral perspective, general means-ends problem-solving
strategies offer guidance about how to select component elements for treatment
targets. First, assess whether the absence of effective behavior is due to a capabil-
ity deficit (i.e., the client doesn’t know how to do the needed behavior) and, if so,
then use skills training procedures. If the client does have the skills but emotions,
contingencies, or cognitive processes and content interfere with the ability to
behave skillfully, then use the procedures and principles from exposure, contin-
gency management, and cognitive modification to remove the hindrances to skill-
ful behavior. Pull disorder- specific procedures and principles from relevant
protocols as needed.
Table 1 uses PICO to illustrate how a modular component treatment plan
might look. Behavioral activation (BA) serves as the basic template and starting
point. BA is based on the premise that depression results from a lack of reinforce-
ment. Consequently, you can treat multiple targets, such as problematic drinking,
insomnia, parenting strategies, and the marital relationship, through the robust
common procedure of activation assignments to reduce avoidance (which inter-
feres with reinforcing contingencies) and improve mastery and satisfaction (to
improve reinforcement). You can use disorder-specific principles and strategies
60
drawn from specific evidence-based protocols (e.g., for insomnia, problem drink-
ing, or parent training) in a modular fashion to treat specific targets.
Beyond the Therapy Room: Organizations and

Practice-Based Science
Diagnostic categories, with current procedural terminology (CPT) codes for diag-
noses and service arms for specific disorders, still organize the world of service
delivery and reimbursement. This organization is not adequate to implement the
vision discussed in this chapter. In order to move into a new era of EBP, organiza-
tional changes must be made to facilitate and support these practices.
Evidence-informed heuristics are emerging to guide these changes, including
identifying key variables that determine and sustain “good enough” implementa-
tion (e.g., Damschroder et al., 2009; Proctor et al., 2009) and verify the utility of
modular components models (Chorpita et al., 2015; Weisz et al., 2012). By insti-
tuting progress monitoring as part of standard practice, practitioners and organi-
zations may be able to answer for themselves what is necessary to obtain good
outcomes within their quality improvement efforts (Steinfeld et al., 2015). As
barriers to practice-based research appear to be surmountable (Barkham, Hardy,
& Mellor-Clark, 2010; Koerner & Castonguay, 2015), and newer single-case
methods make it possible to aggregate data in meaningful ways to draw generaliz-
able conclusions (Barlow, Nock, & Hersen, 2008; Iwakabe & Gazzola, 2009),
practice-based research can offer significant contributions to the scientific
literature.
Conclusion
The ubiquity of EBP implies that it is a straightforward process. However, signifi-
cant challenges due to weaknesses in both the evidence base and clinical judg-
ment suggest that practitioners and organizations create “kind” environments
that will facilitate EBP. By implementing standard work routines, including the
systematic use of heuristics that integrate the best current science, it becomes pos-
sible to train and better calibrate clinical judgment to detect valid cues and learn
the relationships between clinical judgment, interventions, and outcomes. It also
becomes possible to answer practice-based questions and to make significant con-
tributions to the wider research literature. Many hands are going to be needed to
advance the goal of science in practice.
61

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PROCESS-

Distributed in Canada by Raincoast Books

Copyright © 2018 by Steven C. Hayes and Stefan G. Hofmann

Cover design by Amy Shoup

Acquired by Catharine Meyers

Edited by James Lainsbury

Indexed by James Minkin

All Rights Reserved

Library of Congress Cataloging-in-Publication Data on file

1 The History and Current Status of CBT as an

2 The Philosophy of Science As It Applies to Clinical Psychology����� 23

4 Information Technology and the Changing Role of Practice������������ 67

5 Ethical Competence in Behavioral and Cognitive Therapies������������ 83

6 Core Behavioral Processes�������������������������������������������������������������������� 101

7 What Is Cognition? A Functional-­Cognitive Perspective���������������� 119

8 Emotions and Emotion Regulation������������������������������������������������������ 137

9 Neuroscience Relevant to Core Processes in Psychotherapy���������� 153

10 Evolutionary Principles for Applied Psychology���������������������������������179

15 Arousal Reduction���������������������������������������������������������������������������������� 245

16 Coping and Emotion Regulation���������������������������������������������������������� 261

17 Problem Solving�������������������������������������������������������������������������������������� 273

18 Exposure Strategies�������������������������������������������������������������������������������� 285

19 Behavioral Activation���������������������������������������������������������������������������� 299

20 Interpersonal Skills�������������������������������������������������������������������������������� 309

21 Cognitive Reappraisal���������������������������������������������������������������������������� 325

22 Modifying Core Beliefs�������������������������������������������������������������������������� 339

23 Cognitive Defusion�������������������������������������������������������������������������������� 351

24 Cultivating Psychological Acceptance������������������������������������������������ 363

25 Values Choice and Clarification���������������������������������������������������������� 375

26 Mindfulness Practice ���������������������������������������������������������������������������� 389

27 Enhancing Motivation �������������������������������������������������������������������������� 403

28 Crisis Management and Treating Suicidality from a

29 Future Directions in CBT and Evidence-­Based Therapy���������������� 427

Steven C. Hayes, PhD

Stefan G. Hofmann, PhD

Many psychologists may not be aware of the implicit assumptions that

The History and Current Status of CBT

Stefan G. Hofmann, PhD

Steven C. Hayes, PhD

The Inter-­Organizational Task Force on Cognitive and Behavioral Psychology

of Evidence-­based Programs and Practices (NREPP) of the US Substance Abuse

Problems with the Biomedical Model

developing empirically supported treatments to consider these factors by examin-

Defining the Targets of Psychotherapy and

genetic, biological, psychological, and developmental processes as the primary

Why Classify Mental Disorders?

explained by the higher-­order dimensions of negative and positive affect; this

Research Domain Criteria

Moving Toward Core Dimensions in

Moving Toward Core Processes in CBT

change in a contextually specific way. Longitudinal designs are allowing clini-

The Philosophy of Science As It

Sean Hughes, PhD

Part 1: A Brief Introduction to Philosophy

The epistemological question. Epistemology, the theory of knowledge, is con-

belief?” When applied to science, “knowledge” refers to scientific theories, expla-

The axiology question. Axiology refers to the relationship between knowledge

Philosophical assumptions are interactive. Note that questions about episte-

Conclusion. When we articulate our philosophical assumptions, we are articulat-

2 The Philosophy of Science As It Applies to Clinical Psychology�� 23

4 Information Technology and the Changing Role of Practice�� 67

5 Ethical Competence in Behavioral and Cognitive Therapies�� 83

6 Core Behavioral Processes�� 101

7 What Is Cognition? A Functional-Cognitive Perspective�� 119

8 Emotions and Emotion Regulation�� 137

9 Neuroscience Relevant to Core Processes in Psychotherapy�� 153

10 Evolutionary Principles for Applied Psychology��179

15 Arousal Reduction�� 245

16 Coping and Emotion Regulation�� 261

17 Problem Solving�� 273

18 Exposure Strategies�� 285

19 Behavioral Activation�� 299

20 Interpersonal Skills�� 309

21 Cognitive Reappraisal�� 325

22 Modifying Core Beliefs�� 339

23 Cognitive Defusion�� 351

24 Cultivating Psychological Acceptance�� 363

25 Values Choice and Clarification�� 375

26 Mindfulness Practice �� 389

27 Enhancing Motivation �� 403

29 Future Directions in CBT and Evidence-Based Therapy�� 427

The Inter-Organizational Task Force on Cognitive and Behavioral Psychology

of Evidence-based Programs and Practices (NREPP) of the US Substance Abuse

explained by the higher-order dimensions of negative and positive affect; this

Evidence-based practice (EBP) originated in medicine to prevent errors and to

cues). In such high-validity or “kind” environments, there are stable relationships

• Narrow framing—binary do/don’t do rather than “What are the ways I

• Confirmation bias—we pretend we want “truth,” but all we want is

• Short-term emotion—we churn but the facts don’t change.

• Overconfidence—we think we know more about how things in the future

#2 Problem Brief intervention for problem Reduces amount and frequency

#3 Insomnia CBT for insomnia (CBT-I); CBT-I over medications;

#3 Couples Devise activation assignments If individual changes fail to