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Cognitive · 2020

Process-Based Therapy (PBT)

Change becomes precise when the functional process organising this person's suffering in context is modified, measured, and readjusted.

Process-Based Therapy (PBT) is a contemporary meta-framework that proposes reorganising psychological intervention around target biopsychosocial processes rather than disorder-specific manualised protocols. Developed primarily by Steven C. Hayes and Stefan G. Hofmann, PBT integrates contextual behavioural science, the cognitive-behavioural tradition, and transdiagnostic research to identify mechanisms of change operating at different levels (cognitive, emotional, behavioural, relational, and biological). The model maintains that psychological problems emerge from dynamic networks of dysfunctional processes and that treatment should be selected functionally according to which processes maintain suffering in each specific case. PBT is not a closed set of techniques but an evidence-based clinical decision-making system grounded in idiographic measurement and dynamic functional analysis. Its proposal rigorously distinguishes change processes from therapeutic procedures: processes are theoretically grounded, dynamic, progressive, contextually bound, modifiable, multilevel changes that orient towards desirable outcomes, whereas procedures are the specific methods used to mobilise them. The Extended Evolutionary Meta-Model (EEMM) organises case exploration across six psychological dimensions—affect, cognition, attention, self, motivation, and overt behaviour—nested within sociocultural and biophysiological levels, and asks clinicians to analyse in each how variations are generated, which consequences select them, what retains them, and which contexts determine their function. Clinical practice takes the form of continuous process-based functional analysis: beginning with concrete problems and aspirations; constructing a descriptive network of events and relationships; formulating hypotheses about maintenance loops and target processes; selecting empirically supported intervention kernels; measuring proximal and outcome changes; and reformulating the network when the data indicate that the initial hypothesis should be revised. PBT can incorporate procedures from different models, but requires theoretical coherence, process-based evidence, and an explicit functional rationale for every choice. (Hofmann & Hayes, 2018; Hayes, Hofmann, & Ciarrochi, 2020; Hayes, Hofmann, & Stanton, 2020; Hofmann, Curtiss, & Hayes, 2020; Hofmann, Hayes, & Lorscheid, 2021). The Learning Process-Based Therapy manual makes this proposal concrete through three integrated tools: the network map for representing functional relationships among events, the EEMM for ensuring exploration of the six psychological dimensions and two contextual levels, and the VRSCDL lens for analysing variation, selection, retention, context, dimension, and level. A formulation is validated not by its narrative elegance but by its capacity to generate testable predictions: if a kernel modifies the target process in the expected context, related nodes and outcomes should change coherently; if this does not occur, the result is incorporated as information with which to redraw the hypothesis. Treatment progresses from accessible and measurable processes towards more complex configurations and concludes by strengthening self-sustaining adaptive loops through practice, support, integration into routines, and generalisation to relevant contexts. (Hofmann, Hayes, & Lorscheid, 2021).

Theory of change

The person changes when the processes maintaining their suffering are identified and the nodes that reorganise the entire system are targeted precisely.

Core ideas

  1. Therapeutic focus should be on processes, not diagnoses

    PBT maintains that categorical disorders are not homogeneous causal units but descriptive groupings of heterogeneous symptoms. Effective intervention requires identifying modifiable mechanisms maintaining suffering in each particular individual, shifting the focus from diagnostic category to empirically studied dynamic transdiagnostic processes. Diagnosis may retain communicative, administrative, or epidemiological utility, but should not replace functional analysis of what occurs in a particular life. (Hofmann & Hayes, 2018; Hayes et al., 2020).

  2. PBT is a meta-framework, not a closed technical package

    PBT is neither a single new form of therapy nor a proprietary list of exercises. It is a vision of evidence-based practice linking change processes to evaluable procedures and allowing different traditions to contribute when they offer coherent models and methods capable of modifying relevant processes. This openness does not eliminate the need for theory: a technique is legitimately integrated only when its function, process target, and method of evaluation are defined. (Hofmann & Hayes, 2018; Hayes, Hofmann, & Stanton, 2020).

  3. Process and procedure are not synonymous

    A process is the functional change considered responsible for movement towards a goal; a procedure is the clinical action used to influence it. This distinction prevents the conclusion that a technique works simply because it was applied and requires asking which mechanism is expected to change, how that movement will be tested, and whether the change relates to a valued outcome. The same procedure may mobilise several processes, and the same process may be addressed through different procedures. (Hofmann & Hayes, 2018; Hofmann et al., 2020).

  4. Psychological problems emerge from interdependent dynamic networks

    Psychological distress is explained not by a single isolated deficit but by recursive interaction among cognitive, emotional, behavioural, physiological, and contextual processes. PBT adopts a dynamic-systems perspective in which small changes in relevant nodes or relationships may generate cascading effects, while other relationships keep the system rigid through self-amplifying loops and retention patterns. (Hayes et al., 2020; Hofmann et al., 2020).

  5. Clinical formulation is a continuous data-based process

    Case conceptualisation is not a static initial event but a dynamic hypothesis that is constantly reviewed through idiographic measurement and repeated monitoring. PBT integrates systematic collection of individual data as a constitutive part of the therapeutic process, reducing decisions based on untested intuition and making it possible to detect when an assumed relationship, priority, or procedure needs to change. (Hayes, Hofmann, & Stanton, 2020; Hofmann et al., 2020).

  6. Personalisation goes beyond automatic application of a standardised protocol

    Although manualised protocols have demonstrated average efficacy, PBT holds that individual variability requires personalised interventions based on the patient's specific process profile. Personalisation is not eclecticism but systematic application of individualised functional principles: defining which process operates, in which context, for which goal, with which procedure, and with which marker of change. (Hofmann & Hayes, 2018; Hayes et al., 2020).

  7. The EEMM organises change processes without reducing them to a single school

    The Extended Evolutionary Meta-Model provides a common language for considering affect, cognition, attention, self, motivation, overt behaviour, and sociocultural and biophysiological levels. Its function is not to impose a final theory of the person, but to prevent formulation from overlooking relevant dimensions and to allow processes from different traditions to be organised within a functional, multidimensional, multilevel architecture. (Hayes et al., 2020; Hayes, Hofmann, & Stanton, 2020).

  8. Variation, selection, retention, and context explain both maintenance and change

    PBT uses the VRSCDL lens to analyse which alternatives exist, which consequences select a response, what retains it, and which conditions modify its function at the appropriate dimension and level. This lens explains why a pattern may provide short-term relief or belonging while simultaneously damaging long-term health, relationships, or autonomy; it also guides the construction of sustainable adaptive variants. (Hayes et al., 2020; Hayes, Hofmann, & Stanton, 2020).

  9. Process centrality informs but does not replace clinical strategy

    A highly connected node may be a relevant target, but not necessarily the first one. Strategy must consider safety, readiness, resources, capacity to tolerate activation, contextual constraints, and the potential to first address a more accessible process that enables later interventions. PBT combines network analysis with sequential clinical judgement and does not propose automatically attacking the most central element. (Hayes, Hofmann, & Stanton, 2020).

  10. Intervention must test process changes, not only global outcomes

    Symptom improvement is important, but by itself does not confirm what produced change or guarantee that learning is stable. PBT calls for measuring proximal indicators of the target process, observing whether network relationships change, and evaluating whether those changes link to agreed outcomes. This discipline detects procedures that generate brief relief without transforming the maintaining function and processes that change before the global outcome becomes visible. (Hayes, Hofmann, & Stanton, 2020; Hofmann et al., 2020).

Influences

  • Clinical functional analysis
  • Contextual Behavioural Science
  • Acceptance and Commitment Therapy (ACT)
  • Psychological flexibility model
  • Research on mediators and moderators of change
  • Dynamic systems theory
  • Dynamic network analysis
  • Extended evolutionary synthesis
  • Transdiagnostic research
  • Idiographic measurement and intensive time series

Key references

  • Hofmann, S. G., & Hayes, S. C. (2019). The future of intervention science: Process-based therapy. Clinical Psychological Science, 7(1), 37–50. https://doi.org/10.1177/2167702618772296
  • Hayes, S. C., Hofmann, S. G., & Ciarrochi, J. (2020). A process-based approach to psychological diagnosis and treatment: The conceptual and treatment utility of an extended evolutionary meta model. Clinical Psychology Review, 82, 101908. https://doi.org/10.1016/j.cpr.2020.101908
  • Hayes, S. C., Hofmann, S. G., & Stanton, C. E. (2020). Process-based functional analysis can help behavioral science step up to novel challenges: COVID-19 as an example. Journal of Contextual Behavioral Science, 18, 128–145. https://doi.org/10.1016/j.jcbs.2020.08.009
  • Hofmann, S. G., Curtiss, J. E., & Hayes, S. C. (2020). Beyond linear mediation: Toward a dynamic network approach to study treatment processes. Clinical Psychology Review, 76, 101824. https://doi.org/10.1016/j.cpr.2020.101824
  • Hayes, S. C., & Hofmann, S. G. (Eds.). (2018). Process-Based CBT: The Science and Core Clinical Competencies of Cognitive Behavioral Therapy. New Harbinger.
  • Hofmann, S. G., Hayes, S. C., & Lorscheid, D. N. (2021). Learning Process-Based Therapy: A Skills Training Manual for Targeting the Core Processes of Psychological Change in Clinical Practice. New Harbinger.