Hayes and Hofmann’s paper¹ is much welcome. As they argue, there is a need to re-evaluate assessment and treatment prac­tices that are solely or primarily based on psychiatric diagnoses. Diagnoses do not sufficiently account for individual differences, and additional information is usually needed to implement a psychological intervention. In one of our clinical trials aimed at decreasing the symptoms of depression², participants with an ICD-10 diagnosis of a depressive condition reported 5 to 15 additional psychological problems.

Several significant behavioral problems can be overlooked and left untreated if the treatment providers only focus on one or two syndrome categories. Diagnostic categories could be used, for example, when making decisions regarding financial support in the case of sick leave. However, alternative behavioral assessment models should be used when making decisions about the type of intervention methods that are needed.

If we complete an individual behavioral assessment, for example by applying a case formulation model, it appears that several factors have contributed and continue to contribute to symptoms of depression. Log­ically, this leads to the conclusion that there are several potential ways to treat depression, and that the treatment could focus on several maintaining factors. However, in the field of behavioral science, progress is not facilitated by increasing the number of behavioral treatment models; rather, it is linked to identifying the essential processes that explain the beneficial changes that occur due to psychological interventions.

As Hayes and Hofmann¹ point out, we have seen a considerable increase in the number of studies on psychological processes of change in cognitive behavioral therapies (CBTs). Thus, the focus on intervention studies has turned more toward the question of why psychological interventions are effective instead of just asking if they are effective. However, psychological processes of change appear to be a very complex issue. Several processes may explain why psychological interventions are effective for reducing certain symptoms, and there can be different combinations of processes that are essential when treating symptom X in comparison to symptom Y.

In a study exploring – by the Five Facet Mindfulness Questionnaire (FFMQ)³ – which of the mindfulness facets (observing, describing, acting with awareness, non-judging, and non-reacting) mediated the effects of a mindfulness-, acceptance-, and value-based intervention on three burnout dimensions (exhaustion, cynicism, and reduced professional efficacy), we found that a large spread of mindfulness facets mediated changes in all the burnout dimensions during the intervention⁴. However, only im­provement in non-judging skills mediated the reduction in all burnout dimensions during the follow-up. So, the identification of the psychological processes that mediate changes in symptoms not only during but also after any intervention can help us increase the impact of that intervention and allow a more cost-effective use of resources.

The newer forms of CBT should include an individual behavioral assessment of psy­chological processes. This procedure is far more complex and sophisticated than labeling (or naming) individuals according to diagnostic categories. As Hayes and Hofmann state, the field needs to move towards a process-based functional analysis.

The authors also mention that recent findings would require a major shift in the competences needed for practicing CBT. At present, there is limited evidence of the relationship between therapeutic competence and outcome of psychotherapies, and this relationship is usually found to be weak^{5, 6}. The focus on packages for syndromes, the difficulties in measuring competence, and the limited knowledge about and understanding of the processes of change may have contributed to this. Giv­en the emerging consensus on empirical­ly-established psychological processes of change, we need methods to assess whether the relevant competences have been acquired during training; for example, whether therapists are capable of identifying and targeting central processes of change. There is also a need to develop assessment procedures to evaluate whether professionals are capable of delivering process-based treatments.

Hayes and Hofmann review a significant number of studies identifying processes of change. They propose that it is useful to organize the large number of psychological processes into dimensions, and they classify them into six dimensions. However, it is challenging to limit the classification to so few dimensions. The following are examples of the possible challenges. The dimension “cognition” is suggested to include the process of non-reactivity. This is somewhat problematic, since in the FFMQ³ the subclass of non-reactivity also includes items regarding emotions (e.g., “I perceive my feelings and emotions without having to react to them”). The dimension “affect” is proposed to include distress tolerance. However, this has also been considered to be a behavioral measure of avoidance⁷. Thus, it remains to be seen whether empirically established psychological processes of change can be organized into the proposed six dimensions.

Overall, Hayes and Hofmann argue that the field is ready to move toward person-focused, evidence-based care models. Thus, more attention needs to be devoted to answering the question: why do we do the things we do? This evolution involves several opportunities (including the possibility to consider psychological skills training in prevention efforts at the level of the school environment), but also a variety of challenges.

Hayes 和 Hofmann 的论文¹非常受欢迎。正如他们所说，有必要重新评估仅或主要基于精神病学诊断的评估和治疗实践。诊断不能充分考虑个体差异，通常需要额外的信息来实施心理干预。在我们一项旨在减轻抑郁症状的临床试验中² ，ICD-10 诊断为抑郁症的参与者报告了 5 至 15 个额外的心理问题。

如果治疗提供者仅关注一两个综合征类别，则可能会忽视一些重要的行为问题并且得不到治疗。例如，在做出有关病假情况下的财务支持的决策时，可以使用诊断类别。然而，在决定所需的干预方法类型时，应使用替代行为评估模型。

如果我们完成个人行为评估，例如通过应用案例制定模型，就会发现有几个因素已经并继续导致抑郁症状。从逻辑上讲，这得出这样的结论：有几种潜在的方法可以治疗抑郁症，并且治疗可以集中在几个维持因素上。然而，在行为科学领域，行为治疗模型数量的增加并不能促进进步。相反，它与确定解释由于心理干预而发生的有益变化的基本过程有关。

正如 Hayes 和 Hofmann ¹指出的那样，我们发现认知行为疗法 (CBT) 中关于心理变化过程的研究数量大幅增加。因此，干预研究的焦点更多地转向心理干预为何有效的问题，而不仅仅是询问它们是否有效。然而，心理变化过程似乎是一个非常复杂的问题。有几个过程可以解释为什么心理干预对于减轻某些症状有效，并且与症状 Y 相比，在治疗症状 X 时可能存在不同的过程组合。

在一项通过五方面正念问卷 (FFMQ) ³进行的研究中，正念的哪一个方面（观察、描述、有意识地行动、不评判和不反应）介导了正念、接受、以及对三个倦怠维度（疲惫、愤世嫉俗和职业效能下降）的基于价值的干预，我们发现，在干预期间，正念方面的大量传播介导了所有倦怠维度的变化⁴ 。然而，只有非判断技能的提高才能在后续过程中介导所有倦怠维度的减少。因此，识别在任何干预期间和之后介导症状变化的心理过程可以帮助我们增加干预的影响，并允许更经济有效地利用资源。

新形式的 CBT 应包括对心理过程的个人行为评估。这个过程比根据诊断类别标记（或命名）个体要复杂得多。正如海耶斯和霍夫曼所说，该领域需要转向基于过程的功能分析。

作者还提到，最近的发现需要对实践 CBT 所需的能力进行重大转变。目前，治疗能力与心理治疗结果之间关系的证据有限，而且这种关系通常很弱^{5, 6} 。对综合症包的关注、衡量能力的困难以及对变革过程的有限认识和理解可能是造成这种情况的原因。鉴于对经验确定的心理变化过程正在形成共识，我们需要方法来评估培训期间是否获得了相关能力；例如，治疗师是否能够识别并瞄准变革的核心过程。还需要制定评估程序来评估专业人员是否有能力提供基于流程的治疗。

海耶斯和霍夫曼回顾了大量确定变革过程的研究。他们提出将大量的心理过程组织成维度是有用的，并将它们分为六个维度。然而，将分类限制在如此少的维度是具有挑战性的。以下是可能面临的挑战的示例。建议“认知”维度包括非反应性过程。这有点问题，因为在 FFMQ ³中，非反应性子类还包括有关情绪的项目（例如，“我感知我的感觉和情绪，而无需对其做出反应”）。建议维度“影响”包括抗压能力。然而，这也被认为是一种回避行为措施⁷ 。因此，根据经验建立的心理变化过程是否可以被组织成所提出的六个维度还有待观察。

总体而言，海耶斯和霍夫曼认为，该领域已准备好转向以人为本、基于证据的护理模式。因此，需要更多地关注回答这个问题：我们为什么要做我们所做的事情？这种演变涉及多种机遇（包括考虑在学校环境层面的预防工作中进行心理技能培训的可能性），但也带来各种挑战。