Received: 4 July 2020 | Revised: 14 August 2020 | Accepted: 16 August 2020

DOI: 10.1002/capr.12348

ORIGINAL ARTICLE

Categories of transdiagnostic processes: Qualitative data from

psychotherapy practitioners

António Farinha-Fernandes1 | Nuno Conceição1,2 | Rita Silva1

1
Research Center for Psychological Science (CICPSI), Faculdade de Psicologia, Universidade de Lisboa, Lisboa, Portugal
2
Applied Psychology Research Center Capabilities & Inclusion (APPsyCI), ISPA - Instituto Universitário, Lisboa, Portugal

Correspondence: António Farinha-Fernandes, Faculdade de Psicologia, Universidade de Lisboa, Alameda da Universidade, 1649-013 Lisboa, Portugal.
Email: antonio.fernandes@campus.ul.pt

1 | I NTRO D U C TI O N (Kraemer, Noda, & O’Hara, 2004), others argue that a dimensional
component should be added to the traditional categorical systems,
The processes involved in the development, persistence and main- thus preserving their existence (Helzer, Kraemer, & Krueger, 2006).
tenance of psychopathology have been subject to frequent debate. One such dimensional perspective, for which discussion has
A particular focus of discussion is the one comparing categorical and been reignited in the literature, is the transdiagnostic perspective.
dimensional approaches to diverse psychopathological patterns (e.g. This perspective can be seen as an alternative to the widespread di-
Hopwood et al., 2018; Kraemer, Noda, & O’Hara, 2004; Widiger, vision of psychological disorders in categorical and discrete entities,
1992). Categorical systems rely on signals (observed by the clini- as well as to diagnosis-based interventions. As such, it can offer new
cian) and symptoms (reported by the patient), which are viewed as insights when approaching the underlying processes implicated in
important indicators of the presence of a disorder (such as in the mental health (Dalgleish, Black, Johnston, & Bevan, 2020). A partic-
DSM-V or the ICD-10). There are specific diagnostic criteria for each ular transdiagnostic approach consists of studying and conceptualis-
disorder, and a patient is diagnosed with one or more disorders when ing common processes underlying the development or maintenance
meeting those criteria. Dimensional systems, on the other hand, rate of different disorders (for an example, see the shared mechanisms
patients on different dimensions that aim to consider important approaches as discussed in Sauer-Zavala et al., 2017). It is suggested
individual variability and avoid a dichotomous decision between a that such a transdiagnostic scope could help to reduce the com-
present and an absent diagnosis. An individual is thus assessed in a plexity caused by the high levels of comorbidity observed between
set of domains, which arguably allows to draw a deeper profile of im- various categorical diagnoses (Rodriguez-Seijas et al., 2015; Taylor
pairment or severity across them (Helzer, Kraemer, & Krueger, 2006; & Clark, 2009).
Rodriguez-Seijas, Eaton, & Krueger, 2015). Although this transdiagnostic perspective has recently been
Traditional categorical systems have been subject to extensive gaining more attention, some authors point to its historical roots
criticism in recent years (Hengartner & Lehmann, 2017; Hopwood (Mansell, Harvey, Watkins, & Shafran, 2009; Nolen-Hoeksema &
et al., 2018), in favour of dimensional approaches (e.g. the RDoC ini- Watkins, 2011). For instance, both the psychoanalytic view and the
tiative in Yee, Javitt, & Miller, 2015). These dimensional approaches, first behavioural approaches discussed general principles (e.g. de-
however, can be seen as complementary, instead of substitutive. fence mechanisms in the former, operant and classical conditioning
Psychopathology is widely acknowledged as a dynamic construct, in the latter) that could be applied to several clinical patterns, such as
which has been leading to the discussion of perspectives that can phobia, depression or schizophrenia (reviewed in Nolen-Hoeksema
complement the categorical view, thus allowing for a better under- & Watkins, 2011). This idea has been examined again in more recent
standing of its underlying mechanisms (Nelson, McGorry, Wichers, articles. Serving as an example, Gellatly and Beck (2016) conducted
Wigman, & Hartmann, 2017). While some authors consider that cat- a comprehensive literature review on the role of catastrophic beliefs
egorical or dimensional approaches are more appropriate depending (originally discussed by Ellis, 1962) as a predictor of several disor-
on the clinical circumstances and research questions being addressed ders, such as panic, phobia, health anxiety, obsessive–compulsive

© 2020 British Association for Counselling and Psychotherapy

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FARINHA-FERNANDES et al. 653

disorder, post-traumatic stress disorder, pain and traumatic brain developed a heuristic for developing transdiagnostic models of
injury. psychopathology, explaining the dynamics between risk factors
Overall, there is a growing agreement on the fact that different (distal or proximal) and other moderating factors leading to the
disorders involve dysfunctional versions of processes that vary along sequential development of psychopathology. These authors also
a continuum in the general population, which are observed across sev- describe multifinality as the phenomenon by which risk factors
eral categories. The transdiagnostic approach thus focuses on such lead to multiple comorbid disorders, and divergent trajectories as
dysfunctional processes, aiming to contribute to the understanding the phenomenon through which psychopathology expresses itself
of psychopathology in a more parsimonious way (Harvey et al., 2004; in different ways for different individuals.
Nolen-Hoeksema & Watkins, 2011; Rodriguez-Seijas et al., 2015). McKay, Fanning, and Ona (2011) also identified seven maladaptive
In general, transdiagnostic assessment can arguably be simpler coping strategies that appear to be common to every emotional disorder
and more efficient than traditional assessment, since it allows us (e.g. experiential avoidance, rumination or hostility/aggression), as well
to weigh and combine signals and/or symptoms to understand the as eight transdiagnostic intervention elements associated with specific
severity of the problem, to accommodate the heterogeneity of di- skills (e.g. emotional exposure, mindfulness or interpersonal effective-
agnoses and to provide information about transdiagnostic factors ness training). Likewise, Barlow and collaborators (2011) created a uni-
(Rodriguez-Seijas et al., 2015). Furthermore, this approach can also fied protocol for a cognitive–behavioural transdiagnostic intervention
help to reach interventions that focus on such transdiagnostic as- in emotional disorders. The protocol is based on common principles
pects, thus influencing the various disorders that can be associated such as restructuring maladaptive cognitive appraisals, changing mal-
with them. That is, the identification of transdiagnostic processes can adaptive action tendencies, preventing emotional avoidance and using
translate directly into potential focuses of intervention. It is assumed emotional exposure procedures. This model thus addresses the adap-
that an intervention that reverts the underlying processes of a par- tive and functional nature of emotions, aiming to identify and modify
ticular disorder could lead to positive effects on comorbid secondary maladaptive attempts at emotional regulation, and facilitating the re-
disorders (Harvey et al., 2004; McEvoy, Nathan, & Norton, 2009). For duction of excessive emotional responses to internal and external cues.
example, a study from Feldman, Tung, and Lee (2017) suggests that Finally, Frank and Davidson (2014) developed a transdiagnostic model
individual differences in social skills (i.e. cooperation, assertion, re- for case conceptualisation describing (1) transdiagnostic mechanisms
sponsibility, self-control) may play a role in the association between (vulnerability mechanisms such as neurophysiological predispositions
depressive symptoms and ADHD in youngsters, thus constituting a or learned responses, and response mechanisms such as experiential
potential focus of intervention. La Greca, Ehrenreich-May, Mufson, avoidance or attributional biases); (2) a method to link these mecha-
and Chan (2016) also suggest that the prevention of social anxiety nisms with patients’ problems; and (3) a step-by-step process to guide
and depression in adolescents could benefit from a transdiagnostic therapists through the therapeutic process.
intervention, and discuss the importance of considering peer victi- In sum, the previously presented studies and models have con-
misation as a peer risk factor for these disorders. Consequently, the tributed to the listing of transdiagnostic processes in two ways: by
authors developed a transdiagnostic intervention comprising strate- defining innovative common processes (or known processes that
gies to cope with depression, social anxiety and peer victimisation. were not previously presented as such), and by reinforcing and sup-
There has been a growing search for models that are able to porting the transdiagnostic character of certain processes (when
explain how and why transdiagnostic processes result in the de- they are acknowledged by various authors).
velopment of different psychopathological patterns, as well as for In spite of the fact that there are several authors discussing the
specific processes that, albeit not necessarily inserted in a model, advantages of transdiagnostic approaches, it is important to make sure
are potentially transdiagnostic. For example, Harvey et al. (2004) that these approaches effectively help patients to consider their dif-
thoroughly reviewed empirical studies about the cognitive and be- ficulties and to move towards intervention goals (Dudley, Kuyken, &
havioural processes involved in Axis I disorders on the DSM-IV, Padesky, 2011). In other words, the transdiagnostic perspective might
with the purpose of identifying similar transdiagnostic processes. risk compromising its complexity reduction goal if one cannot find a
These authors discuss five general categories of processes: at- direct link between theory and practice. It is also possible that this
tentional processes, memory processes, reasoning processes, view can be considered more disorganised than specific views and cat-
thought processes and behavioural processes. Baer (2007) later egories for each disorder. In fact, the criteria through which a process
described the practice of mindfulness as a transdiagnostic inter- or intervention can be defined as transdiagnostic are still not clear.
vention-related element. Carey (2008) describes the internal per- Recent articles also reflect an unclear use of different terms when re-
ceptual conflict as a transdiagnostic process and discusses how ferring to the transdiagnostic elements, such as processes, mechanisms
the perceptual control theory can help to understand and resolve and factors (e.g. Gallagher, 2017; LaRowe, Zvolensky, & Ditre, 2019;
this conflict. McEvoy et al. (2009) reviewed 10 treatment trials Zelkowitz & Cole, 2019). Here, we choose to use the transdiagnostic
and a meta-analysis of transdiagnostic interventions, identifying process designation to describe the common aspects across disorders
intervention-related transdiagnostic elements, such as psychoed- that might contribute to their development and/or maintenance.
ucation, cognitive restructuring, exposure or behavioural experi- Furthermore, given the diversity of clinical patterns and ther-
ments. On a different note, Nolen-Hoeksema and Watkins (2011) apeutic approaches, the list of transdiagnostic processes directly
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654 FARINHA-FERNANDES et al.

related to the clinical reality should be far from closed. Other than TA B L E 1 Characterisation of the sample
just immersing oneself in the literature of this specialised area of
Variable M SD n %
knowledge, one can also directly address practitioners in a some-
Age 56.16 (27-79) 13.68
what naturalistic setting. Therefore, we sought clinicians of any
Gender
orientation in order to explore whether there exists qualitative evi-
Male 27 52.94
dence that supports processes that have been explicitly referred to
as transdiagnostic in the literature, as well as other processes that Female 24 47.06

might still be missing such a status. Here, we present an exploratory Nationality

qualitative study, based on the work conducted by clinicians in their USA 30 58.82
last week of sessions, as a potential contribution to the simplification Other 21 41.18
and applicability of the transdiagnostic perspective. Experience
>25 years 29 56.86
≤25 years
1.1 | Study goals and research question 15–25 years 6 11.76
7–15 years 6 11.76
Using a qualitative methodology, we aimed at providing evidence for
3.5–7 years 5 9.8
the recognition of specific transdiagnostic processes by practition-
1.5–3.5 years 4 7.84
ers. We used an exploratory and descriptive approach, relying on
<1.5 years 1 1.96
reports from the participants to describe and conceptualise the phe-
nomena based on the obtained data. Education

The main research question was: ‘What are the processes ac- PhD/PsD/ 42 82.35
EdD
knowledged as transdiagnostic by clinicians?’ Aiming to obtain nat-
M.S./M.A. 5 9.8
uralistic information coming from clinicians’ daily practice, however,
the questions asked to participants were more case-centred, as de- M.D. 3 5.88

scribed in Methods section. B.S./B.A. 1 1.96

prior to participation. An email contact from the researchers was

2 | M E TH O DS provided at this stage, for clarification of any aspect pertaining to
the study. Then, participants were invited to provide the socio-
2.1 | Participants demographic data that allowed us to characterise our sample. After
this, they were presented with two qualitative questions, which
To participate in our study, subjects were required to be psycho- invited them to evoke one or more patients with whom they had
therapy practitioners, independently of their theoretical orientation worked in the past week.
and of total years of professional practice. We used a non-proba- The first question aimed at exploring common processes be-
bilistic sampling methodology, from which a convenience sample tween two or more comorbid disorders/issues in a determined pa-
emerged. Subjects were invited to participate via an email invitation tient of their choosing from their caseload: ‘Pick one client/patient
that included a direct link to a questionnaire (further described in from your last week who has at least two different comorbid disor-
the Procedure subsection), which was destined to members of the ders/issues, but whose problems, or their transformation, reflect a
Society for the Exploration of Psychotherapy Integration (SEPI) and common underlying process’. The second question aimed at explor-
of the Society for Psychotherapy Research (SPR), which were both ing common processes between two or more patients with different
international societies. disorders/issues: ‘Pick two or more clients/patients from your last
A total of 51 subjects voluntarily participated in the study week who have at least two different disorders/issues, but whose
(Mage = 56.16, SD age = 13.68, 24 females). Table 1 shows a general problems, or their transformation, reflect a common underlying
characterisation of our sample, in what pertains to socio-demo- process’.
graphic information, level of education and years of professional Note that, rather than asking clinicians directly what processes
experience. they think are transdiagnostic, we deliberately chose to ask them
to describe what processes are common to either a single patient
with multiple disorders or multiple patients with different disor-
2.2 | Procedure ders. Participants could choose to answer both questions or only
one of them, depending on their will and availability to share more
Participants were asked to fill in an online questionnaire developed or less. We chose to use open-ended questions, since this format
using the Qualtrics platform. First, subjects were presented an in- allows participants to explore and describe their subjective expe-
formed consent form, which they were asked to read and accept rience (Hill, Chui, & Baumann, 2013). This could be formulated as
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FARINHA-FERNANDES et al. 655

a simple, indirect yet focused, clinically anchored task to elicit raw, TA B L E 2 Categories of processes obtained after codification of
naturalistic data to be later analysed by us, without demanding from participants’ answers

participants any explicit reflection about processes they would think No. of
are transdiagnostic. We wanted the data analysis to be conducted Categories sources
on the clinical material they provided, not on their perspectives of Emotional 35
what they would themselves consider transdiagnostic. Behavioural 31
Participating in this study required approximately 30 minutes,
Self-self 29
varying in function of the written communication style of each
Self-other 28
participant, as well as of the quantity of information that they
Insight and awareness 28
were willing to share. Ethics approval was granted by the faculty’s
Cognitive 26
Ethics Committee via written application. Although there were
Skills and learning 22
no incentives for participation, a list of transdiagnostic factors,
as reviewed by the authors, was displayed for participants to Establishing and maintaining therapeutic alliance 22

download after completion if they wished to, as an appreciation Therapy/structure 20

for their time. Body 15
Trauma 14
Family, couple and parenting 11
2.3 | Data analysis Motivational 10
Change consolidation 8
The collected data were analysed in a qualitative manner, using the
thematic analysis methodology (see Braun & Clark, 2006). This ap-
proach allows us to identify, analyse and report relevant patterns may have several diagnoses. Nonetheless, the bundle task served
or themes in a group of data, such as participants' answers to our the purpose of eliciting a good dose of heterogeneous, pluralistic
open-ended questions. The analysis occurs in six stages: (1) famil- data.
iarising with the data; (2) creating the first units of meaning based To analyse the data, we used the qualitative analysis software
on data that is relevant to the research question; (3) grouping these QSR NVivo 11, which allows us to manage data and ideas, to formu-
units of meaning into themes or superior categories; (4) revising the late questions to the data, to create graphical models and to create a
categories that were created and the references that were codified; data report (Bazeley, 2007).
(5) defining and naming the themes that configure a thematic map of
the data; and (6) reporting the story told by the data.
The analysis was performed at the semantic level, through 3 | R E S U LT S
the identification of themes and categories that captured partic-
ipants’ descriptive details in relation to transdiagnostic processes. Following the procedure described by Braun and Clarke (2006), we
As suggested by Braun & Clarke (2006), themes were transformed relied on participants’ answers to extract information that allowed
into categories after they had been reviewed at least three times. us to identify and characterise transdiagnostic processes. On aver-
Furthermore, all categories were formed considering the relevance age, participants used 304.92 words to answer our questionnaire
of the themes for research, even if they were mentioned only once. (SD = 184.74, Max = 735, Min = 58). We further present the results
It is important to mention that the creation of units of meaning was of the thematic analysis.
essentially based on the collected information, although some of the
superior categories are common to previous research and pre-exist-
ing theoretical concepts. 3.1 | Common processes across disorders
Note that we chose here not to specify which information about
which question is being answered because the set of questions con- After analysing and codifying all data, a total of 14 categories of pro-
sisted of a bundle task or a global means to elicit potentially relevant cesses were created: emotional; behavioural; self-self; self-other; in-
clinical material. Therefore, by itself, each question alone does not sight and awareness; cognitive; skills and learning; establishing and
merit to be analysed separately. This task was our way of using an maintaining therapeutic alliance; therapy/structure; body; trauma;
online platform with no direct interaction from the interviewer and family, couple and parenting; motivational; and change consolidation.
yet trying to elicit clinically relevant material in a parsimonious way. Table 2 presents these categories and the total number of
We acknowledge that (a) descriptions of processes common within sources.
persons may (sometimes) differ from those between persons; (b) References and units of meaning coming from participants’
several different disorders are being compared (and different pairs answers allow for a more precise description of these categories.
of disorders may be more or less similar); and (c) not only are several Each of them is comprised of some relevant subcategories of pro-
different disorders being compared, but also the clients described cesses. Verbatim examples, coming from different participants, are
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656 FARINHA-FERNANDES et al.

presented for each category of processes, aiming to illustrate the messages that must be attended to and just because they intrude
subcategories involved. or repeat, that does not mean they are important or valuable to ex-
Emotional processes are related to negative affect, emotional plore’. Another participant shared: ‘Helping the patient understand
(dys)regulation, emotional expression, rejection and intolerance to that the addictive behaviours are an ineffective way to cope with
emotional experiences, acceptance and attendance to emotional ex- the symptoms of PTSD. Helping the patient replace the alcohol ad-
periences, emotional knowledge, emotional contact or experiencing. diction behaviours with mindfulness, breathing to reduce stress/
For example, one participant mentioned: ‘Common processes: poor anxiety of PTSD’.
emotion knowledge, heightened emotional arousal, high value for Cognitive processes relate to thought processes, schemas and
emotional stability, high expectations of self-regulation while they core beliefs, attentional processes, memory processes or reasoning
invalidate their emotional experiences, denial of distress despite processes. For example, one participant revealed: ‘I think the under-
lapses in socio-emotional functioning’. Another participant stated: lying process in this client is thought rumination or preoccupation.
‘Common process: extreme difficulty expressing emotions cathar- He is constantly thinking about his girlfriend's behaviour and how
tically in appropriate contexts (i.e. laughing, crying at appropriate she might cheat on him. This jealousy has persisted throughout all
time)’. his romantic and sometimes even friendly relationships. He also ru-
Behavioural processes comprise behavioural tendencies such minates a lot about things he might have done or said wrong in the
as addiction, aggression, compulsion, behavioural avoidance, be- past’. Another participant disclosed: ‘The underlying process I think
haviours caused by emotional arousal (e.g. self-harm), behavioural underlies both problems is her cognitive rigidity. It's something like if
experiments and exposure, reinforcement, behavioural analysis, it was impossible to her to think more, deeper and differently in her
chain analysis and behavioural activation. For instance, one partic- own experience’.
ipant reflected: ‘Concurrently I am addressing his distorted ideas Skills and learning processes were described in the scope of skill
about negative emotions, systematic avoidance of potentially anxi- training and development, promoting a healthy lifestyle or practising
ety provoking events, unrealistic expectations of emotional stability, new habits, a problem-solving orientation, or promoting adaptive
escapist behaviours, poor emotion knowledge, and behavioural acti- ways of interpreting and responding. For example, one participant
vation’. Another participant offered: ‘The common process appears reflected that: ‘In regards to both issues our work is heightened
to be intolerance of discomfort of any kind, and a compulsive need on enhancing her capacity to identify her internal resistance and
to fix/check on (…)’. to practice letting it go so that she might consider alternative re-
Self-self processes include relational processes between parts sponses’. Another participant identified: ‘Teaching healthy lifestyle,
of the self, self-perception, self-treatment, self-acceptance, sense of implementing behavioural changes in lifestyle: sleep, nutrition, and
self and volition. One participant, for example, referred: ‘I see in both exercise/movement. Education about how the brain functions and
women the same problem (…): a history of development that ham- can be changed through self-directed positive neuroplasticity. Teach
pered the normal growth of self-confidence’. Another participant mindfulness and MBSR to develop self-regulation. Examine interper-
highlighted: ‘The underlying theme is perfectionism. Thus self-criti- sonal relationships, increase awareness of negative impact of disor-
cism, fear of failure, needs to be observably competent’. der on those relationships, and teach/practice communication and
Self-other processes are linked to interpersonal difficulties and empathy to improve the quality of social connections’.
competences, communication style and skills, personal space and In what pertains to establishing and maintaining therapeutic al-
boundaries or lack thereof, safety, regulation of giving and receiving, liance, data included processes such as enhancing motivation and
regulation of autonomy and proximity, conflict/rupture and repair collaboration, strains in the alliance, and identifying, addressing and
processes. For example, one participant mentioned: ‘The underlying exploring those ruptures. For example, one participant shared: ‘In
process for each appears to be interpersonal and affect avoidance. therapy, my fundamental concern in both cases is to attend to each
The restriction of interpersonal contact and avoidance of felt or ex- patient's need for psychological safety within the therapeutic rela-
pressed emotion in each promote the symptoms they experience’. tionship’. Another participant stressed: ‘In this phase the relationship
Another participant stated: ‘I am working with both of them on try- (and analytically speaking the countertransference) is concordant:
ing to recognise when they are engaging in mind-reading, to produce she is coming to therapy, helpful to have assistance, feeling empow-
positive social behaviours, to learn better communication skills, and ered after the sessions and starting to get more everyday structure’.
to de-catastrophise the possibility that others might find them wor- Therapy/structure processes emerged in the context of therapeu-
thy of criticism in some way’. tic responsivity to the patient’s variables or needs, as well as socialis-
Insight and awareness processes are described as reflection, ing the patient into the treatment process and format, together with
engaging in proximal or distal meaning-making, expanding aware- its roles, rules and setting. For example, one participant expressed:
ness, exploring ambivalence, gaining insight and new perspective, ‘Her self-rating and perfectionism hindered her previous therapy, be-
self-monitoring, psychoeducation and mindfulness. For example, cause her doctoral student therapist used a reflective, non-directive
one participant expressed: ‘Currently I am focused with both pa- approach to therapy which tended to upset her more and more as
tients on the notion that thoughts are not facts, they do not tell the she described her symptoms. She sought a transfer, believing that
future and they are not accurate reflections of reality. They are not she needed a more directive intervention style’. Another participant
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FARINHA-FERNANDES et al. 657

emphasised: ‘They ask me for an intervention on the obsessive side empirical reasons to believe that there are important similarities be-
of their pathology, rumination, worry, but have difficulties in working tween some disorders, with interventions that address these com-
in a process way and continuously return to the interpretative way. mon processes potentially representing effective means (McEvoy,
We confronted each other and tried to find a common road together Nathan, & Norton, 2009). The transdiagnostic approach—conver-
towards the symptom goals they asked me to help them solve’. gent, integrative and parsimonious—should be seen as an alternative
Body processes relate, for example, to somatic complaints or approach, potentially complementary, that does not aim at replacing
biological health issues, sleeping, nutrition, tension and relaxation, already existent specific approaches to each disorder—divergent,
burnout, exercise and movement, and disconnection from body and eclectic and creative (Clark, 2009; Mansell et al., 2009). Our ex-
sensations. For example, one participant stated: ‘Common process: ploratory study aimed at analysing which transdiagnostic processes
high somatic expression under emotional stress (i.e. dysregulation, emerged from the experiences of a sample of clinicians.
involuntary movement of head, arms, legs)’. Another participant In terms of superordinate categories, the transdiagnostic pro-
highlighted: ‘I begin by educating my clients about the psychological cesses originating from our sample’s clinical focus and practice are
and physical symptoms of trauma. Then I try to normalise exercise, the following: emotional; behavioural; self-self; self-other; insight
sleep, and other physiological processes’. and awareness; cognitive; skills and learning; therapeutic alliance;
Trauma processes were distinguished as being related to recent or therapy/structure; body; trauma; family, couple, and parenting; mo-
early traumatic contexts, abuse of several types, extreme stress, loss, tivational; and change consolidation.
discrimination processes or harm reduction. For example, one partici- In line with the idea that some processes are common to sev-
pant expressed: ‘All of my clients experience comorbid disorders stem- eral disorders, some of the processes that were mentioned by pre-
ming from Historic Trauma that is generational’. Another participant vious authors were also present in our data. Emotional processes,
argued: ‘Underlying common process, in my opinion, is extensive un- for example, are described in several studies as being common to
processed trauma and loss, which by the way also underlies most or all various clinical patterns (Barlow et al., 2011; McKay et al., 2011).
of the symptoms that are common across diagnoses more generally’. Behavioural processes were also previously mentioned in the lit-
Family, couple and parenting processes included aspects such erature as having a transdiagnostic character (Harvey et al., 2004;
as parenting styles, abandonment by a caregiver or marital separa- McEvoy et al., 2009). Not surprisingly, cognitive processes also
tion. For example, one participant shared: ‘The common underlying emerged as a category in our data, given their strong presence in the
issue is a dysfunctional family system that impaired interpersonal literature (Frank & Davidson, 2014; Gellatly & Beck, 2016; Harvey
functionality in the two patients’. Another participant stressed: ‘The et al., 2004; McEvoy et al., 2009; McKay et al., 2011).
common process in both disorders for this client is massive loss as Other categories, though, are less frequently referred to as
a child, rejection by caregivers, isolation, withdrawal and inability to transdiagnostic in the literature, so attention should be paid to them
establish adult loving relationships’. in future studies, in order to clarify their nature (e.g. motivational
Motivational processes were comprised of aspects such as processes or change consolidation processes). Moreover, when one
dissociation, devaluation, ineffective defences or experiential considers the information in the subcategories of the transdiagnos-
avoidance/interruption, ambivalence or resistance, and conflicting tic processes, somewhat different proposals or slightly new formu-
psychological needs. For example, one participant mentioned: ‘The lations can emerge.
common process is experiential avoidance, and is hindering the cli- As argued in Harvey and collaborators (2004) or Frank and
ents, causing suffering because it keeps them focused on the prob- Davidson (2014), transdiagnostic processes can inform about pre-
lems, preventing decentration and liberation’. Another participant disposing factors, precipitating factors and factors involved in the
stated: ‘A common underlying process is resistance to experience’. maintenance of a disorder or problem, whether they are contex-
Finally, change consolidation refers to processes such as empow- tual, biological or cognitive. Thus, there are various processes that
erment, maintaining balance, processing the experience of change, can contribute to the expression of a clinically significant disorder.
repetition and ongoing exposure to new possibilities, and relapse In line with this notion, we observed that some of the processes
prevention. For example, one participant shared: ‘Another way that participants shared reflect the predisposition of an individual
working has been fostered has been enrolment in the medical clinic's to the development of certain difficulties (e.g. early trauma, parent-
rehabilitation program whereby psychological and physical difficul- ing styles). Also in line with these authors, processes resulting from
ties are addressed holistically’. Another participant concluded: ‘They our data also differ in their nature. For example, while thought
feel better when they do such activities, but it is difficult to get them processes, attentional processes and beliefs are mainly of cognitive
to maintain’. nature, others such as somatic complaints can be associated with
a more biological nature. The process list is quite extensive and
seems to merit further inquiry.
4 | D I S CU S S I O N In terms of limitations to this study, it should be noted that the
sample comprised a relatively small group of therapists who were in-
The great number of existing transdiagnostic models reflects the terested in thinking about their practice using this type of scope. This
growing and incomplete state of this field. There are theoretical and might reflect a more integrative group of therapists who were most
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658 FARINHA-FERNANDES et al.

likely to accept taking part in this study. Also, most of them reported theory to clinical reality by addressing clinicians on this topic and
a great level of clinical experience and were highly qualified, coming on their representations of these types of common processes. The
from international professional societies in the field of psychother- authors’ analysis of clinicians’ representations revealed several cat-
apy, which might reflect more solidified methods of addressing the egories, some of which had been commonly discussed in the litera-
clinical reality or a predisposition to more readily and confidently ture on transdiagnostic treatments and processes, while others were
focus on specific processes rather than others. In particular, we ac- relatively novel. Overall, this study aims to configure an additional
knowledge that in several responses by our participants, it is possible clarification of psychopathological constructs, relying on natural lan-
to infer their specific training models and/or theoretical approaches. guage from practising clinicians to examine potential transdiagnos-
Despite our goal of obtaining naturalistic information based on the tic processes. Not surprisingly, the resultant qualitative data, even
practitioners’ practice, the open-ended questions in the context of though preliminary, point to the need of future studies on transdiag-
our methodology might not have allowed us to go beyond standard nostic processes to embrace a pluralistic, integrative route.
case conceptualisation perspectives, even though the quantity and
heterogeneity of participants and data are already informative for AC K N OW L E D G M E N T S
such a preliminary qualitative exploration. We also recognise that we There was no funding for this study. The authors would like to ac-
could have presented an even more refined subcategorisation of the knowledge all participants who voluntarily took part in the study.
processes. We chose to focus on the more overarching ones, aiming
for a parsimonious contribution to the field. ORCID
Altogether, future studies may use a different methodology (i.e. a António Farinha-Fernandes https://orcid.
more in-depth, extensive interview process) that may be better able org/0000-0002-6136-8410
to further capture psychotherapists’ perspectives, explicitly explor- Nuno Conceição https://orcid.org/0000-0001-8038-5841
ing their uncertainties, struggles, nuances and reflective thinking on
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AU T H O R B I O G R A P H I E S
https://doi.org/10.1037/a0030571.
Hopwood, C. J., Kotov, R., Krueger, R. F., Watson, D., Widiger, T. A.,
Althoff, R. R., … Zimmermann, J. (2018). The time has come for di- António Farinha-Fernandes is a Clinical and Health Psychologist
mensional personality disorder diagnosis. Personality and Mental (MSc) with training in cognitive-behavioural and integrative
Health, 12(1), 82–86. https://doi.org/10.1002/pmh.1408.
counselling/psychotherapy. He develops his professional activity
Kraemer, H. C., Noda, A., & O’Hara, R. (2004). Categorical versus di-
mensional approaches to diagnosis: Methodological challenges. in clinical work with adults and adolescents, both at Faculdade de
Journal of Psychiatric Research, 38(1), 17–25. https://doi.org/10.1016/ Psicologia, Universidade de Lisboa and in a private practice set-
S0022-3956(03)00097-9. ting. In parallel, he collaborates in research projects in the fields
La Greca, A., Ehrenreich-May, J., Mufson, L., & Chan, S. F. (2016).
of Cognitive Psychology and Counselling/Psychotherapy, in an
Preventing adolescent social anxiety and depression and reduc-
ing peer victimization: Intervention development and open trial. effort to contribute to the development of both clinical practice
Child & Youth Care Forum, 45(6), 905–926. https://doi.org/10.1007/ and theory.
s10566-016-9363-0.
LaRowe, L. R., Zvolensky, M. J., & Ditre, J. W. (2019). The role of anx-
Nuno Conceição is a broadly trained clinician, working from an
iety-relevant transdiagnostic factors in comorbid chronic pain and
tobacco cigarette smoking. Cognitive Therapy and Research, 43, 102–
integrative psychotherapy perspective. He has been practis-
113. https://doi.org/10.1007/s10608-018-9957-y. ing psychotherapy with adults since 1999 and half of his pro-
Mansell, W., Harvey, A., Watkins, E., & Shafran, R. (2009). Conceptual foun- fessional life is dedicated to his clients. He also consults and
dations of the transdiagnostic approach to CBT. Journal of Cognitive teaches as Guest Assistant Clinical Professor at Faculdade de
Psychotherapy, 23(1), 6–19. https://doi.org/10.1891/0889-8391.23.1.6.
Psicologia, Universidade de Lisboa since 2011. He directs the
McEvoy, P. M., Nathan, P., & Norton, P. J. (2009). Efficacy of transdiag-
nostic treatments: A review of published outcome studies and future Paradigmatic Complementarity Lab, where he conducts re-
research directions. Journal of Cognitive Psychotherapy, 23(1), 20–33. search on Psychotherapy Integration and trains clinicians at the
https://doi.org/10.1891/0889-8391.23.1.20. Faculty’s Community Service. He is also a professional therapist
McKay, M., Fanning, P., & Ona, P. Z. (2011). Mind and emotions: A uni-
trainer on Psychotherapy Integration modules at professional so-
versal treatment for emotional disorders. Oakland, CA: New Harbinger
Publications. cieties. He was pastpresident of the Society for the Exploration
Nelson, B., McGorry, P. D., Wichers, M., Wigman, J. T. W., & Hartmann, of Psychotherapy Integration.
J. A. (2017). Moving from static to dynamic models of the onset of
mental disorder: A review. JAMA Psychiatry, 74(5), 528–534. https://
Rita Silva is currently working in the Human Resources
doi.org/10.1001/jamap​sychi​atry.2017.0001.
Nolen-Hoeksema, S., & Watkins, E. R. (2011). A heuristic for developing Management area, with a special focus on emotional intelligence,
transdiagnostic models of psychopathology: Explaining multifinality transformational leadership, work life balance, employee en-
and divergent trajectories. Perspectives on Psychological Science, 6(6), gagement and work culture. She is also interested in the fields
589–609. https://doi.org/10.1177/17456​91611​419672.
of effective communication, ethical practice, cross-cultural
Rodriguez-Seijas, C., Eaton, N. R., & Krueger, R. F. (2015). How transdiag-
nostic factors of personality and psychopathology can inform clinical awareness and relationships management. She completed her
assessment and intervention. Journal of Personality Assessment, 97(5), Master’s Degree in Clinical and Health Psychology (Cognitive-
425–435. https://doi.org/10.1080/00223​891.2015.1055752. Behavioural and Integrative Psychotherapy) in 2016 at Faculdade
Sauer-Zavala, S., Gutner, C. A., Farchione, T. J., Boettcher, H. T., Bullis, J.
de Psicologia, Universidade de Lisboa. Her dissertation was fo-
R., & Barlow, D. H. (2017). Current definitions of ‘transdiagnostic’ in
treatment development: A search for consensus. Behavior Therapy,
cused on the transdiagnostic approach.
48(1), 128–138. https://doi.org/10.1016/j.beth.2016.09.004.