A conversation with Stefan Hofmann

480_Stefan_Hofmann_7375(para la versión en español de la entrevista, click aquí).
There is no need for introduction when it comes to Stefan Hofmann. A prolific researcher and writer, he has published over 15 books and more than 200 scientific articles (and more of one of his articles had had the ACT community on their toads, which is a good thing).

We (ie. Paula José Quintero and Fabián Maero), had the opportunity to attend to his conferences at Buenos Aires this year and we asked him for an interview, to which he kindly agreed.

We published the interview in Spanish in Psyciencia (here), but for our international readers -the two of them-, here is the original interview in English.


–[PJQ and FM] Thanks for agreeing to this interview Stefan, could you tell to our readers a little bit about your background and current projects?

[SH] My name is Stefan G. Hofmann and I am a Professor of Psychology at Boston University, where I direct the Psychotherapy and Emotion Research Laboratory. I was born and raised in Germany. I came to the US in 1991 and moved to Boston in 1996. My research focuses on the mechanism of treatment change, translating discoveries from neuroscience into clinical applications, emotion regulation, and cultural expressions of psychopathology. My research is supported by numerous grants from the National Institutes of Mental Health.

More specifically, they include the following: (1) Generalized Anxiety Treatment Evaluation (GATE) Study:  we are conducting a research study comparing the effectiveness of yoga, cognitive-behavioral therapy, and stress education in the treatment of generalized anxiety disorder. (2) Dose Timing of D-Cycloserine to Augment CBT for Social Anxiety Disorder: a research study on the effectiveness of tailored d-cycloserine administration for social anxiety disorder. (3) D-Cycloserine to Enhance CBT for Social Anxiety Disorder: This study is funded by the NIMH examining the effects of d-cycloserine (DCS) to enhance the efficacy of cognitive behavioral therapy for social anxiety disorder. (4) Neurobiological Correlates of Anxiety Disorders: In collaboration with the Massachusetts Institute of Technology, we are currently in the analysis phase of an fMRI study examining the neurobiological correlates of anxiety disorders and the associated changes that occur as a result of treatments.  For more information, see  http://www.bostonanxiety.org/

–We’ve been at your last conferences at Buenos Aires, and we’d like to ask some questions about some of the things that were discussed there. One thing that intrigued us was that you said that CBT shouldn’t be developing focusing solely on the reduction of negative affect, but also to enhance positive affect. What do you think CBT should do differently to address that, both at the level of scientific development and clinical interventions?

Anxiety disorders and depression are associated with negative affect. Chronic negative affect tends to deplete one’s energy and ability to adaptively cope with situational challenges, which in turn exacerbates the experience of negative affect. Whereas negative affect has been assumed to be associated with a limited behavioral repertoire in a given situation (e.g., fear is more likely associated with escape behaviors), positive affect is assumed to broaden the behavioral repertoire. Positive affect is typically associated with approach, whereas negative affect is associated with withdrawal tendencies. Experiencing negative affect that is associated with avoidance tendencies to novel and potentially dangerous situations might have been evolutionarily adaptive because it was more costly to approach a dangerous new situation than it was to avoid a harmless novel situation. As a result, the propensity is higher to respond to negative information than to positive information. On the flip-side, avoidance tendencies immunize people from novel experiences. In contrast, positive affect encourages approach behaviors, and stimulates exploration and curiosity. It is possible that the partial segregation of positive and negative affective processing is evolutionarily adaptive, because it encourages the individual members of a species to explore novel situations and environments, despite the potential threat that might be associated with these situations. Therefore, from an evolutionary perspective, it is adaptive to be able to experience both positive and negative affect independently and simultaneously.

In a recent model, I proposed that the core of depression and anxiety disorders is the dysregulation of negative affect, associated with a deficiency in positive affect. Depending on the person’s diathesis and affective style, a positive feedback loop can become established between the disorder, dysregulation, negative affect and affective style, which leads to a chronic condition that becomes difficult to change. Our model assumes that the most effective ways to treat anxiety disorders are by (1) targeting emotion dysregulation by promoting adaptive emotion regulation strategies; (2) decreasing negative affect and increasing positive affect, and (3) promoting adaptive affective styles. The theoretical background and clinical applications of these main components of the model are discussed below.

The model is exposed in more detail in this article, and an extension of this will be published in my book, Emotion in Therapy: From Science to Practice by Guilford Press (to be published in the Spring of 2016).

Interpersonal strategies of emotional regulation

–Another thing you included as a desired development for CBT was the focus on emotions and the incorporation of intrapersonal and interpersonal emotion regulation strategies. Which particular strategies were you refering to –specifically regarding interpersonal strategies of regulation?

–Emotion-focused coping strategies include intrapersonal emotion regulation. Accordingly, emotions can be regulated at various stages in the process of emotion generation: (1) selection of the situation, (2) modification of the situation, (3) deployment of attention, (4) modification of cognitive appraisal, and (5) modulation of responses. Intrapersonal emotion regulation strategies can be broadly distinguished into response-focused and antecedent-focused strategies, depending on the timing during the process that generates an emotion. Antecedent-focused emotion regulation strategies occur before the emotional response has been fully activated. They include tactics such as situation modification, attention deployment, and cognitive reframing of a situation. Suppression is a response-focused emotion regulation strategy that entails attempts to alter the expression or experience of emotions after response tendencies have been initiated.

Emotion regulation is not only limited to intrapersonal processes. In fact, emotion regulation originates in early attachment relationships. An infant’s emotional expression becomes the primary means through which attachment figures are made aware of the infant’s needs. It has been proposed that what begins as the regulation of basic physiological needs via expressed emotions gradually transforms into emotion regulation. Research on attachment has shown that children utilize the secure base as a means of regulating their emotions as they explore their world. By learning that there is a safe place to turn to when distressed, children become more confident that the world is a safe place. This increased confidence is then associated with a reduction of anxiety, allowing infants to move further away from the secure base for extended periods of time.

Emotion regulation becomes a fundamental aspect of human socialization between the ages of 3 and 6 when social regulation evolves. This is the time when a child learns to respond based on other people’s inner states rather than to the outward behaviors and learns to relate the present self to the past self as well as the future self.  This learning process depends largely on environmental input in the form of caregivers’ verbal and nonverbal reactions to children’s emotions, and parents’ expression and discussion of emotion. It develops in the context of parent–child interaction, with both internal and external influences that act on one another over time. As executive functioning develops over time, emotion regulation becomes more intentional and effortful. Therefore, emotion regulation development is closely linked with parental and family influences from early in development, and these influences begin to include the peer context over time.

Emotions and the others

-[SH] I recently proposed a framework of interpersonal emotion regulation that distinguishes intrinsic vs. extrinsic and response-independent vs. response-dependent interpersonal emotion regulation strategies. Intrinsic interpersonal regulation refers to the process when one person’s emotions are regulated by recruiting the help of other people. In contrast, extrinsic emotion regulation is the process in which one person regulates another person’s emotions. These processes can be response-dependent or response-independent. They are response-dependent if the processes rely on a particular response by another person, and they are response-independent if they do not require that the interaction partner responds in any particular way (or may not be able to do so).

In the case of intrinsic interpersonal emotion regulation, a person wants to regulate his or her emotion through the help of another person. An example may be Kathleen, a woman with panic disorder and agoraphobia who is afraid of going to a mall alone. Kathleen is able to do this with either her husband or a doctor friend (Dr. Sarah) by her side. By asking her husband or Sarah to accompany her to the mall, Kathleen is able to regulate (i.e., reduce) her anxiety. Kathleen’ anxiety is regulated through slightly different interpersonal factors, by her husband and Sarah.

Kathleen’s motives to have her husband and Dr. Sarah by her side are slightly different. Simply feeling the presence of her loving husband makes Kathleen feel more at ease, even if he was unable to effectively respond in any particular way in case she experiences a medical emergency (“you will stand by me”). Similarly, Kathleen’s husband might suggest to Kathleen that he accompanies her to the mall for the same reason (“feel my love”). The former is an example for intrinsic response-independent interpersonal emotion regulation, and the latter is an example for extrinsic response-dependent interpersonal emotion regulation.

In contrast to her husband, Kathleen friend, Dr. Sarah, has medical training and could effectively intervene in case Kathleen experiences a medical emergency, which is an example of a response-dependent emotion regulation).  Depending on whether the regulation is motivated by Kathleen (“you will rescue me”) or Dr. Sarah (“I need to make you feel better”), we can again distinguish between intrinsic and extrinsic response-dependent emotion regulation.

Just as intrapersonal strategies can be maladaptive or adaptive to regulate emotions, so can interpersonal strategies be adaptive (if they serve as a buffer of emotion stress) or maladaptive (if they contribute to the maintenance of the problem). The presence of a safety person is an example for a maladaptive emotion regulation strategy. A safety person provides Kathleen a sense of safety, leading to a reduction in the level of her fear typically associated with entering a mall and thereby acting as an emotion regulation strategy. Clinically, it is considered a maladaptive strategy, because the safety person in effect leads to the maintenance of Kathleen’s irrational fear of entering a mall. Frequent or habitual use of interpersonal emotion regulation strategies can conceivably reduce a patient’s sense of control of his or her own emotion experience. Therefore, interpersonal emotion regulation can become maladaptive if a patient becomes dependent on specific individuals or social groups in order to regulate his or her own affect.

Extending emotion regulation to include interpersonal processes offers an interesting transdiagnostic perspective of emotional disorders. Furthermore, it considers the broader (social) context of an individual’s behavior and emotional experience. Despite these advantages, an interpersonal model of emotion regulation shows a number of weaknesses. First, there are no instruments available yet to measure interpersonal emotion regulation strategies. Therefore, the direct empirical evidence for the impact of these strategies on emotional distress is relatively weak. Any assessment instrument will need consider the influence of the cultural context, because interpersonal emotion regulation strategies are directly related to social standards and expectations. Finally, it remains unknown how interpersonal and intrapersonal emotion regulation strategies interact, and the relative importance of these groups of strategies combined are unexplored.

This model predicts that communication trainings are unlikely to succeed unless the functional relationship between the partner’s behaviors and patient’s emotions are being addressed (i.e., how does the partner contribute to the patient’s maladaptive emotion regulation strategies?). For example, the husband might employ extrinsic interpersonal emotion regulation toward his wife in order to deal with his own frustration at work. For example, Kathleen’s husband might reinforce her dependency on him to compensate for his own insecurity and fear that she might leave him she becomes more independent. Communication and problem solving training without considering such interpersonal emotion regulation processes might even accentuate the patient’s presenting problem. The case of Kathleen illustrates these processes and mechanisms of interpersonal emotion regulation.

I discussed this in more detail in this article, and more will be discussed in my upcoming book, Emotion in Therapy.

Third-wave therapies and transdiagnostic processes

– We know that in the past you have been very skeptical of the so-called third-wave therapies. What is your position on that matter today? Do you think there is such a thing as a “third-wave” of CBT, or that it could bring something fresh to CBT?

 The terms “new wave”, “third wave”, “next generation”, and “third generation” of behavior and cognitive behavioral therapy (CBT) is outdated now and few serious researchers and scholars use this term anymore. Steve Hayes and I have become close friends and collaborators and we are working together to build a unifying theory of CBT. We do not view CBT as a single treatment, but rather as a family of interventions that are based on empirical evidence and sound theories.

This is described in detail in my book An introduction to modern CBT: Psychological solutions to mental health problems.

–Considering that there is a lot of research about psychopathological processes that are transdiagnostic (e.g. experiential avoidance or metacognitions): What is your opinion about the transdiagnostic approach on psychopathology?

–Our field is ready to move away from the DSM and its simplistic assumption that psychological problems are expressions of latent disease entities. The word “transdiagnostic” implies that there are interventions that cut across different diagnoses. This is the critical first step away from the DSM and toward a more treatment-relevant classification system. I applaud these efforts.

The DSM controversy

We have a couple of questions regarding the DSM, and since you have been involved as a consultant of the DSM task force you have a privileged perspective on it. As you know, there has been a big controversy around the 5th edition of the manual, specifically regarding to its reliability and the pathologization of normal human experiences (as in the removal of the bereavement exclusion for major depressive disorder), what do you think about the manual and these issues?

Aside from political and financial issues (the DSM-5 is a major source of income for the American Psychiatric Association), some of the frequently raised arguments included the following (in random order): the DSM-5 pathologizes normality using arbitrary cut-points; deriving a diagnosis is merely based on subjective judgment by a clinician, rather than objective measures, such as biological tests; the DSM-5 is overly symptom-focused and ignores the etiology of the disorder; the DSM-5 categories include a heterogeneous group of individuals and a large number of different symptom combinations can define the same diagnosis; the comorbidity problem (i.e., co- occurrence of two or more different diagnoses) remains unresolved; and most clinicians will continue to use the residual diagnosis (“not otherwise specified”) because most patients do not fall neatly into any of the diagnostic categories, which are derived by consensus agreement of experts. Essentially the same concerns also apply to the 11th edition of International Classification of Diseases of the World Health Organization, which is due by 2015. I agree with many of these critcisms and I think that it is time that we start thinking about an alternative and treatment-relevant classification system that avoids the problems by the DSM and ICD. This will require a departure from the simplistic medical model that is based on the latent disease model.

We’ve been discussing a recent article of yours in which you proposed a model of complex causal networks as an alternative to the DSM classification. To be honest, we’ve never heard about the CCN approach before. Could you tell to our readers a little bit about its core features and why do you think it is a better approach than the current alternative?

–This is one of the most promising alternatives to the latent disease model. I am in the process of developing this further and the article will appear in Perspectives of Psychological Science. I also discuss it briefly here.

Just briefly, instead of assuming the existence of latent disease entities underlying symptoms, the network approach assumes that disorders exist as systems of inter-related elements/psychological problems. In the case of psychopathology, the elements of the network may be maladaptive behaviors, cognitive biases, emotional disturbance, and physiological abnormalities. That complex systems can take on bi-stable states via critical transitions is highly relevant to clinical science. This approach offers fresh new perspectives and methods for clinical science.  In a highly connected network, which is often the case in mental health, the shift from one state to the other is seldom linear.  Rather, the change often occurs abruptly once the system reaches a tipping point. Longitudinal within-subject tracking of symptoms will enable clinical researchers to identify critical transition points signaling impending recovery and relapse.

Loving-kindness meditation for depression

–It was unexpected for us to learn that you were researching a protocol of loving-kindness meditation for depression. And the preliminary results were astonishing! What do you think are the mechanisms of change involved in that kind of practice?

Loving-kindness (metta in Pali), which is derived from Buddhism, refers to a mental state of unselfish and unconditional kindness to all beings [12]. When practicing LKM, the person gently repeats certain phrases in order to direct a positive energy of feeling, called metta, towards other people, as well as oneself. Metta refers to a mental state of unselfish and unconditional kindness to all beings. This meditation practice is believed to broaden attention, enhance positive emotions, and lessen negative emotional states. It is believed to shift a person’s basic view of the self in relation to others and increase empathy. Therefore, LKM may be particularly useful for improving positive affect and reducing negative affect, such as anxiety and mood symptoms in clinical populations. For further reading, the articles are this one and this one.

–Thanks Stefan for your time!