We appreciate the rich, thought-provoking paper by Hayes and Hofmann¹, including their inspiring account of the work of so many intervention scientists on whose shoulders we all stand. The directions they propose warrant close attention by all of us who seek to strengthen psychotherapies. Here, we focus specifically on how their ideas may apply to youth psychotherapy and idiographic treatment of youth mental health challenges.

Youth and adult psychotherapy have obvious similarities, but differ in ways relevant to Hayes and Hoffman’s analysis: a) caregivers’ involvement in accessing and participating in their children's treatment highlights the salience of caregiver support and “styles of family functioning”, which Hayes and Hofmann identify as mediators of outcome; b) youths, unlike adults, often begin treatment at the behest of their caregivers and teachers, not for intrinsic reasons, and this can make motivational processes especially critical to success in youth therapy; c) youth developmental stage may impact the accessibility and ef­ficacy of some therapeutic processes (e.g., recursive reasoning about one's own cog­nitions; regulation of attention and emotion through mindfulness and sense of self, prominent in some “third-wave” therapies).

These caveats notwithstanding, much of the authors’ analysis is directly relevant to youth psychotherapy. For example, they stress that, although psychotherapy protocols have often outperformed comparison conditions, advances in efficacy to date have “been inhibited”. This perfectly characterizes the youth psychotherapy literature. In a recent meta-analysis², we synthesized findings of 453 randomized controlled trials of youth psychotherapies, spanning five decades. Across time, mean effect sizes have not changed significantly for treatment of anxiety and attention-deficit/hyperactivity disorder (ADHD), and have declined significantly for depression and conduct problems.

Those worrisome findings were complemented by an analysis of the potential for improvement of current psychotherapies³. Using a meta-analytic copula approach with 502 randomized trials, we predicted youth psychotherapy effect size as a function of therapy quality. Our results indicated that a currently available therapy of “perfect quality” would have an estimated effect size of Hedges’ g=0.83, conferring (via common language effect size) a 63% chance – only 13% better than a coin-flip – that the average treated youth would improve more than the average control group youth. This suggests, consistent with Hayes and Hofmann, that truly major improvements in therapy benefit may require fundamental changes in our interventions.

But, aren’t new and different therapies being designed every year? Yes, but the challenge has been to create new therapies that are not skeuomorphic – new in some respects but retaining unnecessary and potentially counterproductive features of their predecessors⁴. Optimizing advances may require both building on strong foundations and breaking the mold. Hayes and Hoffman wisely note the value of leveraging the strengths of existing therapies when innovating, making intervention development evolution, not revolution. We agree. The challenge may lie in striking the delicate balance between incorporating decades of evidence on what works, and shedding structures that are based in tradition or habit, rather than evidence.

Achieving the right balance could involve, as the authors suggest, focusing on change processes and making treatment more idiographic, less standardized. They suggest “moving away from treating psychiatry labels toward treating the individual patient by understanding the process-based complexity of his/her problems and applying tailored intervention strategies”. Our efforts, and those of our colleagues, to apply such an approach in youth psychotherapy have led to the creation of treatments that are modular, transdiagnostic, and personalized using measurement-based care. In one version, called MATCH^{5, 6}, 33 components (i.e., “modules”) of evidence-based treatments for anxiety, depression, trauma, and conduct problems – all derived from decades of research by our predecessors – are organized into a menu of treatment options. Clinicians use this menu to design treatment idiographically, guided by decision tools and an individual dashboard showing each youth’s treatment response, updated weekly. Although decades of research inform its content, MATCH departs from traditions such as treating just one psychiatric disorder and using a standardized sequence of sessions – potential skeuomorphs but, at a minimum, not features that research has shown to be essential for beneficial outcomes.

In a second step of idiographic design, we have organized youth psychotherapy around empirically supported principles of change, honoring ideas previously proposed by many leaders in the field⁷. The resulting FIRST protocol^{8, 9} synthesizes treatment procedures within five principles: calming and self-regulation, cognitive change, problem-solving, positive opposite behaviors (e.g., exposure, behavior­al activation), and motivation for change. This principle-guided approach rests on the rationale that learning specific procedures is useful, but perhaps most useful to therapists who understand why they are using certain techniques – i.e., which change processes need to be set in motion to produce real benefit. In FIRST, as in MATCH, treatment is fully idiographic, with individualized intervention guided by clinician decision tools and repeated mea­surement of each youth’s functioning and treatment response.

Early evidence on these idiographic ap­proaches has been both encouraging and revealing, highlighting what youth psychotherapy research suggests may be three key challenges for process-based psychotherapy. One challenge is clinical decision-making. As treatments become less standardized and more idiographic, clinicians will be required to decide, for each youth, which processes to target, in which order and in which combinations, and with which specific procedures, given multiple options supported by evidence. A critical long-term task for intervention science will be developing strategies for guiding such decision-making, and determining the optimal blend of data-driven and clinician-guided judgment.

A closely-related challenge will involve enriching and deepening clinical assessment to capture the underlying processes that need attention in treatment – processes that may be key to therapeutic success. Our field has a long history of assessment focused on diagnosis and symptoms, and a respectable track record within some of the process dimensions identified by Hayes and Hofmann – for example, cognitive reappraisal, rumination, worry, and catastrophizing. However, the newer, deeper, contextually-focused processes identified by the authors – such as cognitive diffusion, flexibility, non-reactivity, and “healthy psychological distance from thought” – may well require new measures, and possibly entirely new assessment strategies.

A third challenge will be discerning the implications of process-based psychotherapy for what many consider the holy grail of intervention science: identifying mechanisms of change. There is a long history in our field, well-documented by Hayes and Hofmann, of efforts to elucidate mediators of therapeutic change. Documenting mediators is a statistical step toward identifying mechanisms that account for treatment benefit – the switches that, when flipped, make therapy successful.

An implicit assumption historically has been that we will eventually discover the mechanisms of change (or perhaps a small number of them) for treatment of each psychiatric disorder. A process-based analysis turns this thinking upside down in at least two ways: a) treatment focuses not on disorders but on underlying processes, and b) treatment is tailored to each individual, targeting complex underlying processes that matter for that individual. Under these conditions, do we continue the search for mechanisms of change and, if so, are we searching for “flip switches” as diverse and distinctive as the individuals our interventions are designed to support?

Taken together, there is much that intervention scientists – including those of us immersed in youth psychotherapy – can learn from the perspective offered by Hayes and Hofmann. Clearly, exciting challenges lie ahead in process-based psychotherapy.

我们感谢 Hayes 和 Hofmann ¹撰写的内容丰富、发人深省的论文，包括他们对众多干预科学家所做工作的鼓舞人心的描述，我们都站在他们的肩膀上。他们提出的方向值得我们所有寻求加强心理治疗的人密切关注。在这里，我们特别关注他们的想法如何适用于青年心理治疗和青年心理健康挑战的具体治疗。

青年和成人心理治疗有明显的相似之处，但在与 Hayes 和 Hoffman 的分析相关的方式上有所不同：a) 看护者参与和参与他们孩子的治疗突出了看护者支持和“家庭功能风格”的显着性，Hayes 和 Hofmann确定为结果的中介；b) 与成年人不同，青少年经常在他们的照顾者和老师的要求下开始治疗，而不是出于内在原因，这使得激励过程对于青少年治疗的成功尤其重要；c) 青年发展阶段可能会影响某些治疗过程的可及性和有效性（例如，对自己认知的递归推理；通过正念和自我意识调节注意力和情绪，在某些“第三波”疗法中尤为突出）。

尽管有这些警告，但作者的大部分分析与青年心理治疗直接相关。例如，他们强调，尽管心理治疗方案的表现通常优于比较条件，但迄今为止疗效的进步“受到抑制”。这完美地描述了青年心理治疗文献。在最近的一项荟萃​​分析^{2 中}，我们综合了 453 项青年心理治疗随机对照试验的结果，跨越了五个十年。随着时间的推移，治疗焦虑症和注意力缺陷/多动障碍 (ADHD) 的平均效应量没有显着变化，而在抑郁症和行为问题上则显着下降。

对改善当前心理治疗的潜力的分析补充了这些令人担忧的发现³。使用 502 项随机试验的荟萃分析 copula 方法，我们预测青年心理治疗效果大小作为治疗质量的函数。我们的结果表明，目前可用的“完美质量”疗法的估计效应大小为 Hedges 的 g=0.83，赋予（通过共同语言效应大小）63% 的机会——仅比抛硬币好 13%——平均接受治疗的青年会比普通对照组青年进步更多。这表明，与 Hayes 和 Hofmann 一致，治疗益处的真正重大改进可能需要我们的干预措施进行根本性的改变。

但是，不是每年都在设计新的和不同的疗法吗？是的，但挑战在于创造非拟物化的新疗法——在某些方面是新的，但保留了前辈不必要的和可能适得其反的特征⁴。优化进展可能需要建立在坚实的基础上并打破常规。Hayes 和 Hoffman 明智地注意到在创新时利用现有疗法的优势的价值，使干预发展演变，而不是革命。我们同意。挑战可能在于在整合数十年关于有效方法的证据与摆脱基于传统或习惯而非证据的结构之间取得微妙的平衡。

正如作者所建议的那样，实现正确的平衡可能涉及关注变革过程，并使治疗更加具体化，不那么标准化。他们建议“通过了解患者问题的基于过程的复杂性并应用量身定制的干预策略，从治疗精神病学标签转向治疗个体患者”。我们和我们的同事在青年心理治疗中应用这种方法的努力已经导致使用基于测量的护理创建模块化、跨诊断和个性化的治疗方法。在一个版本中，称为 MATCH ^5、6, 针对焦虑、抑郁、创伤和行为问题的循证治疗的 33 个组成部分（即“模块”）——所有这些都来自我们前辈几十年的研究——被组织成一个治疗选项菜单。临床医生使用此菜单根据决策工具和显示每个年轻人治疗反应的个人仪表板的指导，根据具体情况设计治疗，每周更新一次。尽管数十年的研究为其内容提供了信息，但 MATCH 偏离了传统，例如只治疗一种精神疾病并使用标准化的治疗顺序——潜在的拟物化，但至少不是研究表明对有益结果至关重要的特征。

在具体设计的第二步中，我们围绕经验支持的变革原则组织了青年心理治疗，尊重该领域许多领导者先前提出的想法⁷。由此产生的 FIRST 协议^8、9综合了五个原则内的治疗程序：​​平静和自我调节、认知改变、解决问题、积极的相反行为（例如，暴露、行为激活）和改变的动机。这种以原则为导向的方法基于这样一个基本原理，即学习特定程序是有用的，但也许对理解为什么的治疗师最有用他们正在使用某些技术——即，需要启动哪些变更流程才能产生真正的收益。在 FIRST 中，与 MATCH 一样，治疗完全是个体化的，在临床医生决策工具的指导下进行个性化干预，并反复测量每个年轻人的功能和治疗反应。

关于这些具体方法的早期证据既令人鼓舞又具有启发性，突出了青年心理治疗研究表明的可能是基于过程的心理治疗的三个关键挑战。一项挑战是临床决策。随着治疗变得不那么标准化和更加个性化，临床医生将需要为每个年轻人决定针对哪些过程、以何种顺序和哪种组合以及采用哪些特定程序，并提供有证据支持的多种选择。干预科学的一项关键长期任务将是制定指导此类决策的策略，并确定数据驱动和临床医生指导判断的最佳组合。

一个密切相关的挑战将涉及丰富和深化临床评估，以捕捉治疗中需要注意的潜在过程——这些过程可能是治疗成功的关键。我们的领域有着悠久的评估历史，专注于诊断和症状，并且在 Hayes 和 Hofmann 确定的一些过程维度中有着可观的记录——例如，认知重新评估、沉思、担忧和灾难化。然而，作者确定的更新、更深层次、以语境为中心的过程——例如认知扩散、灵活性、非反应性和“与思想的健康心理距离”——很可能需要新的措施，可能需要全新的评估策略。

第三个挑战是识别基于过程的心理治疗对许多人认为的干预科学的圣杯的影响：确定变化的机制。在我们的领域有很长的历史，海耶斯和霍夫曼有详细记录，努力阐明治疗变化的中介。记录介质是确定治疗获益机制的统计步骤——转换时，使治疗成功的开关。

一个隐含的假设历史上一直是我们最终会发现的变化的机制（或者少数人），治疗每一个精神疾病的。基于过程的分析至少在两个方面颠覆了这种想法：a) 治疗的重点不是疾病，而是潜在的过程，以及 b) 针对每个人量身定制的治疗，针对对个人很重要的复杂的潜在过程。在这些条件下，我们是否继续寻找变化的机制，如果是，我们是否正在寻找与我们的干预措施旨在支持的个体一样多样化和独特的“翻转开关”？

总的来说，干预科学家——包括我们这些沉浸在青年心理治疗中的科学家——可以从海耶斯和霍夫曼提供的观点中学到很多东西。显然，基于过程的心理治疗面临着令人兴奋的挑战。