Process based therapy

 

You’ve probably heard a lot about process based therapy. Here’s a quick orientation to it, and then some follow-up readings. I hope that a process-based approach will help empower you to be a more flexible, creative, and effective practitioner.

Process based therapy is not a replacement for other psychological therapies. It’s a shift in focus. For example, somebody could do psychodynamic therapy, schema based therapy,positive psychology coaching, or cognitive behaviour therapy in a process based way.

An example of a process-based case conceptualization for a single individual

Process based therapy helps us to shift from thinking in terms of evidence based packages to evidence processes inside those packages. So instead of saying this CBT protocol is evidence based and you have to use the whole protocol with every single person, we can identify the evidence based processes within the protocol.

This gives us a lot more flexibility and creativity, because we don’t have to use the whole protocol with every single client, and we can cross therapeutic islands and use techniques from different approaches together, within the same coherent framework. Pretty cool huh?

Process-based therapy seeks to look inside therapeutic block boxes, or protocols, to identify the active processes.

The above example illustrates what we’re up to here. We often evaluate therapeutic packages like a black box. We don’t know what ingredients are inside, and which ingredients we need for each client. A process based approach lets us open the box, and examine what are the evidence-based processes. I’ve given a few examples here, such as those targeting cognition, affect, and overt behaviour. Once we break the package down into evidence-based processes, we’re now free to use components of the package that, based on our case conceptualisation, are most relevant to our client. For example, not every client needs to be taught how to think of problems as challenges rather than threats. Not every client will need an emphasis on goal setting.

The process based metatheory underpinning process-based therapy is called the extended evolutionary metamodel (EEMM; Hayes, Hofmann, & Ciarrochi, 2020). I know that’s a mouthful, but don’t worry, you can read about it if you’d like to know more. There are follow-up readings below. Here are a couple of important points about the EEMM.

  • We can use the EEMM to understand other theories. It’s not restricted to one therapeutic approach. Rather, It’s based on the one theory that every single therapeutic island accepts: evolution. Thus we hope it will allow us to create a shared language that everybody can use, in every therapeutic orientation, to communicate their amazing insights.
  • The key drivers of change in this model are: variation, selection, retention, in a particular context. For example, if someone is struggling and seeking help, that means they need a change. You’ll need to support them to try something new (variation). Then they’ll discover if that new behaviour builds value, meaning and health (selection). Finally when they find what works, they need to make sure the new behavior “sticks” (retention). Maybe they’ll develop habits or morning rituals or change their environment so that it’s easier to engage in value consistent behaviour.
The evolutionary meta-model attempts to provide a kind of common language for all therapies, a periodic table of evidence based processes. All processes can be classified as involving the dimensions of cognition, attention, affect, motivation, self, and overt-behaviour. The figure below presents an example of the process and how they might be linked to the hexaflex and DNA-V models of ACT.

Learn more about DNA-V here

Learn more about the hexaflex model here or here

DNA-V Process Label
Hexaflex Process Label
Extended evolutionary meta-model
Purpose of intervention
DiscovererCommitted Action

Overt Behavior

Use trial-and-error learning. Help people to willingly engage in new or nontypical behaviour, to develop their skills and resources, and expand their context.
NoticerPresent moment awareness; acceptanceAttention
Affect
Physiological states and responses		Help people notice inner and outer experience and have the capacity to accept rather than or avoid or cling to it. Help people attend to the present context.
AdvisorDefusionCognitionHelp people to navigate their context with language and disengage from unhelpful language processes
ValuesValuesMotivationCreate contexts that empower people to clarify what they value, choose value consistent action and sustain action across time and hardship
Self-viewSelf-as-contentSelf-as-process
Self-as-context
SelfHelp people take perspective on themselves, overcome self-limiting beliefs or categories, view self with compassion, and take actions towards self that are self-enhancing rather than self-destroying.
Social-ViewAll six processes at the social levelAll six dimensions above at social levelHelp people to take perspective on others, to recognize social interdependence and the value of others, and to behave effectively in social situations
DNA-V Process Label
Hexaflex Process Label
Discoverer Committed Action
NoticerPresent moment awareness; acceptance
AdvisorDefusion
ValuesValues
Self-view Self-as-contentSelf-as-process
Self-as-context
Social-View All six processes at the social level
Extended evolutionary meta-model
Purpose of intervention
Overt Behavior
Use trial-and-error learning. Help people to willingly engage in new or nontypical behaviour, to develop their skills and resources, and expand their context.
Attention
Affect
Physiological states and responses		Help people notice inner and outer experience and have the capacity to accept rather than or avoid or cling to it. Help people attend to the present context.
Cognition Help people to navigate their context with language and disengage from unhelpful language processes
Motivation Create contexts that empower people to clarify what they value, choose value consistent action and sustain action across time and hardship
SelfHelp people take perspective on themselves, overcome self-limiting beliefs or categories, view self with compassion, and take actions towards self that are self-enhancing rather than self-destroying.
All six dimensions above at social level Help people to take perspective on others, to recognize social interdependence and the value of others, and to behave effectively in social situations

The extended evolutionary meta model doesn’t replace hexaflex or DNA-V. Rather, it let’s us put the two frameworks side-by-side and understand how they relate.

The process-based approach will help you understand what you emphasise in your own practise and what you may want to do more of. It’ll also allow you to explore other therapeutic orientations, knowing that you can always classify the process within that orientation inside the extended evolutionary metamodel. Finally, it gives you flexibility with clients. You can use different processes, in different orderings, with different clients, depending on what they need. For example, with a mandated client you may emphasise value clarification and building a relationship. In contrast if you have a fully engaged client who already has a high level of emotional awareness, but is not engaging in helpful behaviour, you might emphasise activating overt behaviour. In this way, process-based approaches help you personalise your interventions.

Follow this new journey of process based therapy with these follow up readings.

Books on process-based intervention

Hofmann, S. G., Hayes, S. C., & Lorscheid, D. N. (2021). The Process-Based Therapy Workbook for Clinicians: Targeting the Core Processes in Psychological Change . New Harbinger Publications.

A process based approach to unifying positive psychology

Ciarrochi, J., Hayes, S., C., Oades, L.G., & Hofmann, S.G. (2022). Toward a unified framework for positive psychology interventions: Evidence-based processes of change in coaching, prevention, and training. Frontiers in Psychology, 12.

Appendix to above: Detailed listing of positive psychology processes and findings

Process-based psychotherapy: chapters

Ciarrochi, J. Hayes, S., Hayes,L, Sahdra, B.,Ferrai, M., Yap, K, & Hofmann, S. From package to process. An evidence-based approach to processes of change in psychotherapy. Comprehensive Clinical Psychology: Foundations. Gordon Asmundson

Hayes, S.C., Hofmann, S.G., Ciarrochi, J. (2020). Building a process-based diagnostic system: An extended evolutionary approach. In Hayes, S.C. & Hofmann, S.G., Beyond the DSM: Toward a Process-based Alternative for Diagnosis and Mental Health Treatment. Oakland, CA: Context Press.

Hayes, S., Hofmann, S., Ciarrochi, J. (2020). Creating an alternative to syndromal diagnosis: Needed features of processes of change and the models that organize them. . In Hayes, S.C. & Hofmann, S.G., Beyond the DSM: Toward a Process-based Alternative for Diagnosis and Mental Health Treatment. Oakland, CA: Context Press.

Process-based psychotherapy: Articles

Hayes, S.C., Ciarrochi, J., Hofmann, S., Chin, F., Sahdra, B.(2022). Evolving an idionomic approach to processes of change: Towards a unified personalized science of human improvement.Behavior Research and Therapy. 

Hayes, S.C., Hofmann, S.G., Ciarrochi, J. (2020). A process-based approach to psychological diagnosios and treatment: The conceptual and treatment utility of an extended evolutionary model. Clinical Psychology Review, 82.

Ciarrochi, J. (2021). The coming revolution in intervention science: From Standardized protocols to personalized processes. World Psychiatry,20, 385-386.

Hayes, S.C., Hofmann, S.G., Stanton, C.E., Carpenter, J.K.,Sanford, B.T., Curtis, J.E., & Ciarrochi, J. (2019). The role of the individual in the coming era of process-based therapy. Behaviour Research and Therapy,117,40-53.