What Is Process-Based Therapy and Why Now?

If you were to look in my therapy office, you would see books on cognitive-behavioral therapy for panic disorder, dialectical behavior therapy for borderline personality disorder, and emotionally focused therapy for distressed couples. Like many therapists, I have dozens of treatment manuals to treat many disorders.

There are over 500 psychological therapies, and it’s nearly impossible for a therapist to learn all the interventions for specific diagnoses. I employ evidence-based approaches but rarely follow the manual page by page. To address each client’s context, comorbidity of diagnoses, specificity of presentation, and individual factors impacting their mental health, I take an integrative approach, personalizing treatment for the client’s unique presentation.

That is why I was intrigued by process-based therapy (PBT). Instead of specific protocols for syndromes, PBT focuses on the underlying mechanisms (processes) that drive psychological problems. PBT aims to offer a more unifying psychology that bridges many therapy models and customizes treatment to each client’s context and unique presentation.

PBT is not a new therapy to add to the list of 500, but rather a new way of conceptualizing therapy.

PBT addresses the bio-psycho-social context of the client, is flexible and dynamic, and encourages the therapist to bring their training, background, and strengths into the treatment room. Therapists and clients are empowered to build on what they already know works, disrupt systems that are not working, and apply effective treatment kernels to change the underlying mechanisms that keep the client stuck.

I am not an expert in PBT, as this treatment is fairly new, with articles being released as I write this. This blog post offers my perspective as a practicing evidence-based psychologist on the strengths of PBT, how it differs from current treatment approaches, and why I am now embracing this fresh approach.

You Are an Individual in a Context, Not a Syndrome in a Box

The first strength of PBT is that it offers a new paradigm for viewing mental health. For the past 50 years, medical and mental health providers have communicated about their client’s problems through the lens of a diagnostic system. The Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 2013) or the International Classification of Diseases (ICD; WHO, 2018) have been the dominant approach. These systems classify individuals based on meeting criteria for a cluster of symptoms. Recently, there has been increasing criticism of this approach. Treating syndromes with rigid protocols has been criticized for having poor specificity, a high overlap of diagnoses, and overly broad treatment implications.

For example, suppose I had a client come to my office reporting that they have been experiencing chronic worry, difficulty sleeping, physical tension, and decreased concentration at work. In that case, I might use the DSM-5 or ICD-10 criteria to diagnose the client with generalized anxiety disorder (GAD). I may then turn to the manuals on my bookshelf and follow a protocol of CBT for GAD. Yet, what if I also learned that this client is a therapist during the COVID-19 pandemic who is a single mother, stopped exercising due to the increased demands at work, and is highly self-critical of her performance as a mom and a therapist?

A diagnosis of GAD falls short of describing the full context of the client and gives only a little insight into the most effective places to intervene. In contrast, a process-based approach would work with the client to diagram all the factors influencing the client’s experience of stress and worry. In this client’s case, the therapist may work on interventions that target processes such as self-compassion, mindfulness, social support, and physical activity.

Instead of focusing on “protocols for syndromes,” PBT maps out the complex interacting factors maintaining client problems. Rather than asking which protocol should be used for which symptom, PBT asks, “What core biopsychosocial processes should be targeted with this client given this goal in this situation, and how can they most efficiently and effectively be changed?”

Toward Processes of Change

A second strength of PBT is its focus on processes central to therapy’s effectiveness. In the book Learning Process-Based Therapy, Hoffmann, Hayes, and Lorscheid (2021) write, “Shifting to a PBT framework requires reframing our questions in the field of clinical psychology from, ‘What treatments work?’ to ‘How do treatments work?”

What are the underlying processes behind how treatments work? Professors Steven Hayes, Stefan Hoffman, and Joesph Cirraochi asked that question when they undertook a meta-analysis of over 55,000 treatment outcome research studies. In what they call the ‘Deathstar Project,” these researchers looked at mediating variables that contribute to change. If a client improves in therapy, what contributed to their improvement? What were the mechanisms or processes of change?

Once a therapist identifies a key change process, they can employ an individualized intervention based on client and therapist characteristics. For example, I am trained in body-based and compassion-focused therapy interventions. If it becomes clear that a client’s anxiety is worsened by self-criticism, I may choose to target the process of self-compassion using compassionate imagery and soothing rhythm breathing. However, a more cognitively oriented therapist may target self-criticism by having the client write down compassionate self-statements to read during the week.

Although there are common maladaptive processes that clients can get stuck in, many different interventions could be helpful for these processes. PBT allows therapists to tailor interventions based on their client’s stuck points and therapeutic orientation.

Multidimensional Modeling

Another strength of PBT is that it addresses the complex bio-psycho-social factors contributing to mental health. To be human includes having thoughts, attention, motivations, emotions, behaviors, and a sense of self. To be human also includes having social networks, cultural influences, and bio-physiological factors that impact your well-being.

PBT organizes change processes into six dimensions (motivation, cognition, affect, behavior, attention, and self) and two levels (bio-physiology and socio-cultural). There are adaptive and maladaptive processes within each of these dimensions and levels.

For example, in the dimension of cognition, is the client able to step back from their thoughts and reframe them in a way that empowers them (adaptive), or do they believe unhelpful thoughts to be true (maladaptive)? In the domain of attention, can the client flexibly attend to the present moment (adaptive), or are they scattered and distracted (maladaptive)?

The multidimensional model also includes two levels influencing a client’s well-being: bio-physiology and sociocultural factors. The bio-physiological level assesses factors such as sleep, diet, exercise, and neurophysiology. The sociocultural levels include cultural beliefs, social support, stigma, and prejudice.

A Network-Based Approach

A final strength of PBT is that it takes a systems approach to understanding client problems. PBT encourages therapists to view clients’ challenges as existing in networks with feedback loops and maintaining multidirectional factors. Using a network diagram, therapists draw out how life events and biopsychosocial processes interact so they can plan where to intervene to produce the most meaningful change.

No one therapeutic orientation is favored; what is focused on instead is the effectiveness of the intervention on the process that keeps a client stuck. Therapists then can assess interventions on an ongoing basis and, with feedback on what is working and what is not, can adjust the intervention and the network model.

The Future of Mental Health

Process-based therapy is not a new therapy. It’s a new approach to therapy that honors evidence-based interventions, individual differences of clients, contextual and systemic factors influencing clients, and therapists’ strengths and training. It takes flexibility on the part of a therapist to enter a new paradigm, yet with flexibility, variation, selection, and retention, comes evolution and growth. I hope treatment providers will be open to exploring a more unified, less divisive approach to therapy. Together, we can go beyond labeling people as symptoms and syndromes and embrace humans as dynamic and interconnected beings who benefit from personalized, contextual, evidence-based, and compassionate care.

Listen to my conversation with Dr. Joseph Ciarrochi on Your Life In Process to learn more about Process-based Therapy.