Commentary on Hofmann and Hayes: The Water Looks Inviting,but How and When Do We Jump in?

Hofmann and Hayes (2019; this issue, p. 37) challenged the field to look both backward and forward to recognize progress made, but also missed opportunities, in developing and delivering mental health services that can effectively and efficiently reduce the burden of mental illness. They present what is in many ways a simple premise: Empirically supported processes of change should guide treatment planning, rather than treatment packages. Although I might quibble with whether or not we really need a new name for this approach (they use the term process-based therapy), I agree with the basic argument and believe it can provide a valuable approach to addressing comorbidity, the need to better integrate nomothetic and idiographic approaches, and the limitations of a disorder-based diagnostic approach that fails to “carve nature at its joints.”

Moreover, as Hofmann and Hayes noted, this is not a new idea and there have been exciting strides made in this direction already. For instance, groundbreaking work over the past 15 years has focused on how to extract the common elements from evidence-based intervention packages that lead to effective mental health outcomes for children (e.g., Chorpita, Daleiden, & Weisz, 2005). Further, Hofmann and Hayes hope that “in the future, it might further be possible to train paraprofessionals in specific therapeutic procedures to target the therapeutic processes that more highly trained professionals identify as the most promising treatment targets” (p. 43). This wish for greater dissemination may be less futuristic than they suppose. There is already considerable evidence that nonspecialist providers can effectively deliver treatment strategies based on common processes of change (drawn from well-established behavioral, interpersonal, emotional, and cognitive therapy approaches) in low- and middle-income countries. A recent review of 27 trials found a moderate to strong pooled effect size in favor of the active interventions, even when the treatments were mainly delivered by peers or community health workers (Singla et al., 2017). This raises considerable hope for the potential of a process-based therapy approach to have wide reach.

The real question, then, is less should we train the next generation of providers to focus on becoming proficient in targeting key processes of change, and more how can we get there? We are swimmers sitting by the edge of the pool—the water looks inviting, but how and when do we jump in? This is a difficult question because so much is not yet known. For instance, what is the final list of change processes that would be recommended, and for which problem areas would these processes be effective and under what circumstances? And how do we know which combinations of change process strategies should be used for which client, or the optimal way to sequence the strategies? These are not easy questions to address given that the data on mechanisms and on personalization of treatments are not nearly as good as we wish (or desperately need them to be; see Teachman, Beadel, & Steinman, 2014). Thus, the fundamental question raised by Paul (1969) still remains unanswered when we shift to a process-based therapy approach: “What treatment, by whom, is most effective for this individual with that specific problem, under which set of circumstances, and how does it come about?” (p. 44).

These many unanswered questions challenge our identity as clinical scientists who want a strong base of empirical evidence to guide decision making. And yet, I would argue that it is time to take the plunge and get wet (at least in the shallow end!). We, as a field, need to do something different given how woefully ineffective we have been at reducing the burden of mental illness in a meaningful way (see Kazdin & Blase, 2011). Moreover, it will be more feasible to answer Paul’s million-dollar question with a process-based approach because the process-based approach is designed to be individualized and starts as a treatment that can be readily dismantled to determine its necessary and sufficient parts, rather than those questions often being addressed decades after traditional treatment packages have been introduced.

So, how do we “get in the pool” in an ethical and scientific way, given the unknowns? Clearly, the answer to this question will require a book, rather than a brief commentary, but a few initial steps that seem helpful include the following:

Much remains unknown about how to shift from a treatment package to a process-based therapy approach and what impact this shift will have, but the time has come to “jump in the water.” For the sake of our clients and their families, we cannot sit on the sidelines any longer.