The Process-Based Future

Authors: Stefan Hofmann, PhD & Steven C. Hayes, PhD

For nearly 50 years, intervention science has pursued the dream of establishing evidence-based therapy by testing technological protocols for syndromes in randomized controlled trials. Many clinicians do not yet realize it, that era is ending.

The scientific assumption that was the foundation of the “protocol for syndromes” era was the idea that human suffering is likely a latent disease. In physical medicine, diseases have known causes; they unfold in ways that fit with underlying mechanisms; and they have known and characteristic responses to treatment. Syndromes are just clusters of signs and symptoms. The funders hoped to find the underlying mental diseases and their causes by making sure everyone targeted carefully measured syndrome in their research on mental health, and targeted them with well-specified techniques or medications so that their response to treatment could be specified. Then, they hoped, we could work backward to find the etiology and mechanisms of action of specific types of psychopathology. Finding true psychiatric diseases, they believed, would finally put mental illness a scientifically sound footing, equal to that of any health area.

It didn’t happen. Decades passed and billions were spent but as of today the field of mental health has yet to identify its first major psychiatric disease.

As a result, in the last several years NIMH has changed its strategy. In other areas of medicine, when syndromes did not lead to the identification of etiology and mechanisms, the field turned to a more process-based and personalized focus.  For example, when labelling the different types of cancer defined by their location and appearance did not lead quickly enough to a better understanding of how cancer originated and operated, oncologists started focusing more on things like oncogenes, or epigenetic regulation of cell growth. This in turn lead to a better understanding of the mechanisms involved in cancer, and new treatment methods targeting these processes came on line, improving outcomes.

The field of clinical invention science is making a similar turn. The field already has a leg up because in the last decade and a half especially a great deal of information has been gathered on processes of therapeutic change. In broad strokes, studies of mediation and moderation have specified some of the sequences of client change that are functionally important to good outcomes. We finally have in hand analytic methods that will allow us to examine those relationships person by person.

The is the core idea that underlies Process Based CBT (PB-CBT). Instead of asking what syndrome someone “has,” and what protocol might best change “it”, the core clinical questions in PB-CBT is:

“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?”

Biopsychosocial change processes can be organized into manageable sets, that help fit intervention elements to client characteristics. For example, one client may be suffering because of his own emotional rigidity, and his resulting inability to make use of emotional information. Another person may be dominated by the life narrowing impact of her own self-concept. Both may share particular signs or symptoms -- high levels of anxiety, for example -- but the role of this anxiety differs in two cases and the methods to address anxiety thus may need to differ as well.

In a more process-based approach, empirical clinical work is then not a matter of following a cookbook-like treatment protocol, nor is it adhering to one technological approach over another. Instead, effective clinical work is a matter of using available methods to move these evidence-based processes in the context of the specific needs and goals of particular people. Specific models (e.g., such as the generic CBT model; or the psychological flexibility model) can be useful in this approach because they organize sets of processes into manageable, but techniques used are secondary to the targeted processes of change.  

Traditional CBT prospered in the era of protocols for syndromes. Some of the areas in which it struggled—processes of change, theoretical development, clarity about philosophical assumptions—were brought into heightened relief with the arrival of the “third wave” of behavioral and cognitive therapies. New methods and new assumptions challenged the status quo.

Superficially, it appeared as though the change was all about acceptance, or mindfulness, or values. But it was deeper than that. The most important thing about the third wave was that it anticipated the transition to a more process-based model of evidence-based care.

See also: ACT: Redefining Health and Wellness

    The publication of our book Process-Based CBT (Hayes, & Hofmann, 2018) and expansion of these ideas into diagnosis, treatment, and research (Hayes & Hofmann, 2017; Hofmann & Hayes, 2018) is leading to a new way to think about CBT and all of evidence-based treatment. Examining individual client characteristics in the light of evidence-based processes of change means a kind of evidence-based therapy that is individualized, dynamic, fitted to client goals and values, and adjusted to the situation and available mode of delivery—and that can draw on every intervention kernel known to be helpful in changing a given process. In short, PB-CBT is a reversion to the tradition of functional analysis, except now as armed with a vast array of studies on functionally important processes of change, and with statistical and assessment methods adequate to a more idiographic form of evidence-based care.

That “back to the future” day has arrived.

CBT clinicians no longer need to think of themselves as having to live inside a given narrowly defined set of methods, drawn from particular generations of the tradition. The change to PB-CBT opens up CBT even to evidence-based processes drawn from humanistic, existential, or analytic traditions.

Stefan and I were known combatants during the rise of “third-wave” in CBT. We have seen how a process approach has made it much easier to address our own differences. We predict it will have the same impact on you.

If you want to explore PB-CBT, there are several ways to begin. Start with the book itself (it is a text so if you teach in this area, it is ideal). The text has a series of related video products to supplement your learning. Stefan and I are conducting a Praxis webinar session on PB-CBT and this fall we will conduct the first Praxis workshop on PB-CBT September 29-30, in Boston.


Steven C. Hayes, University of Nevada, Reno

Stefan G. Hofmann, Boston University




Hayes, S. C. & Hofmann, S. G. (2017). The third wave of CBT and the rise of process-based care. World Psychiatry, 16, 245-246. doi: 10.102/wps.20442

Hayes, S. C. & Hofmann, S. G. (2018). (Eds.), Process-based CBT: The science and core clinical competencies of cognitive behavioral therapy. Oakland, CA: Context Press / New Harbinger Publications.

Hofmann, S. G. & Hayes, S. C. (2018). The future of intervention science: Process based therapy. Clinical Psychological Science. Doi: 10.1177/2167702618772296

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