What Is Process-Based Therapy?

A 34-year-old woman comes in with a diagnosis of generalized anxiety disorder. She has tried CBT twice. Both therapists taught her cognitive restructuring and behavioral activation. Both courses of treatment helped for a few months and then stopped working.

The problem was not that CBT failed. The problem was that her anxiety was not primarily maintained by the processes CBT targets.

Her assessment data revealed a different picture: experiential avoidance (she organized her entire day around avoiding specific emotional states), low distress tolerance (any uncomfortable feeling triggered an escalating sequence of worry, reassurance-seeking, and then shutdown), and rigid self-rules about what counted as acceptable performance at work. The anxiety was the output of these three interacting processes, not a standalone disorder that responded to a standalone protocol.

Process-based therapy starts from this observation. Your distress is maintained by specific psychological processes operating in a specific pattern, and treatment should target those processes rather than the diagnostic label attached to them.

The Shift from Protocols to Processes

Traditional evidence-based therapy works like this: you receive a diagnosis, and the diagnosis determines your treatment protocol. Major depressive disorder gets behavioral activation and cognitive restructuring. Generalized anxiety gets worry exposure and relaxation training. Anorexia gets family-based treatment or CBT-E. The protocol is the same regardless of which specific processes maintain the disorder in your case.

This works well for many people. But it also explains why treatment effect sizes across mental health have plateaued since 2000. The Dodo Bird verdict, the finding that most therapies produce roughly equivalent outcomes, is not evidence that all therapies work equally well. It is evidence that matching people to protocols by diagnosis is an imprecise targeting mechanism.

Steven C. Hayes and Stefan G. Hofmann formalized this critique in 2018 with the process-based therapy framework. Their argument: the unit of analysis should not be the disorder or the protocol but the functional process. Instead of asking “Does CBT work for depression?” we should ask “Which therapeutic procedures change which processes, for which people, in which contexts?”

How It Works in Practice

Process-based therapy uses three interlocking components.

Assessment of functional processes. Before selecting interventions, the clinician maps which psychological processes are operating in your specific case. These might include experiential avoidance, rumination, cognitive fusion (treating thoughts as literal truths), interpersonal rigidity, attentional bias, low self-compassion, or dozens of other identified processes. The assessment is idiographic: it describes your pattern, not a category average.

Selection of change procedures. Once the maintaining processes are identified, the clinician selects interventions from across therapeutic traditions that have evidence for changing those specific processes. This might mean drawing from ACT for experiential avoidance, EFT for attachment injuries, DBT for distress tolerance, and psychodynamic work for relational patterns, all within the same treatment. The interventions are selected because they target the right process, not because they belong to the right brand.

Network analysis. Processes do not operate in isolation. They form networks where changes in one process propagate through the system. The clinician identifies which processes are most central (most connected to other processes) and which are most modifiable with available interventions. This determines where treatment begins.

Who It Helps

Process-based therapy is particularly useful when standard protocol-based treatment has produced incomplete results. If you have tried an evidence-based treatment and improved but plateaued, PBT asks whether the treatment was targeting the right processes or whether the maintaining processes in your case differ from what the protocol assumes.

It is also useful for complex presentations that span diagnostic categories. When someone has an eating disorder and relationship distress and vocational paralysis, a diagnosis-based approach treats each category separately. PBT asks whether common processes (perfectionism, experiential avoidance, shame) maintain all three problems simultaneously, and whether targeting those shared processes produces broader change.

Clinical populations where PBT has been applied include anxiety disorders, depression, eating disorders (including ARFID), gambling disorder, substance use, chronic pain, couples distress, and PTSD.

The Evidence Base

PBT draws its evidence from the components literature rather than whole-package RCTs. The question is not “Does PBT work?” but “Does targeting specific processes produce measurable change in those processes and in downstream symptoms?”

The answer, across hundreds of component studies, is yes. Targeting experiential avoidance reduces avoidance and co-occurring symptoms. Targeting cognitive flexibility increases flexibility and reduces depressive relapse. Targeting emotion regulation improves regulation and reduces binge eating. The process-targeting evidence is strong even when the whole-package evidence for any single brand of therapy is modest.

Hayes and Hofmann’s 2018 framework synthesizes this component evidence into a coherent clinical model. The Extended Evolutionary Meta-Model (EEMM) provides the theoretical architecture, organizing processes into six dimensions: cognition, affect, attention, self, motivation, and overt behavior.

What Makes It Different from Eclectic Therapy

Clinicians who draw from multiple approaches sometimes describe their work as “eclectic” or “integrative.” PBT is distinct from eclecticism because the selection of interventions is evidence-guided rather than preference-guided. The clinician does not choose techniques because they feel right or because the clinician is most comfortable with them. The clinician chooses techniques because assessment data identified specific processes, and the selected interventions have component-level evidence for changing those processes.

The difference is accountability. In eclectic therapy, the rationale for intervention selection is often implicit. In PBT, the rationale is explicit: this process was identified, this intervention targets it, and we will measure whether the process actually changed.

Process-Based Therapy in My Practice

I built the Idiographic Clinical Network System (ICNS) to implement process-based therapy in clinical practice. ICNS uses ecological momentary assessment (repeated brief check-ins throughout the week) to collect data on 15+ psychological processes as they operate in a patient’s daily life. The data is analyzed using vector autoregression and network analysis to identify which processes are most central and most modifiable.

The result is a personalized network map showing how your specific processes interact, which ones drive the most downstream effects, and where intervention is likely to produce the largest systemic change. Treatment targets shift as the network changes across sessions.

This is not theoretical. I use ICNS with patients at Center for Discovery, and the network maps have consistently identified maintaining processes that standard diagnostic assessment misses.

Frequently Asked Questions

What is process-based therapy?

Process-based therapy (PBT) is a therapeutic framework that identifies and targets the specific psychological processes maintaining your distress, rather than matching a diagnosis to a protocol. Instead of asking 'What disorder do you have?' PBT asks 'What patterns are keeping you stuck?' and builds treatment around the answer.

How is process-based therapy different from CBT?

CBT applies a standardized protocol based on your diagnosis. Process-based therapy identifies the unique combination of processes maintaining your specific problem and selects interventions from across therapeutic traditions that target those processes. Two people with the same diagnosis might receive different PBT interventions because their maintaining processes differ.

What conditions does process-based therapy treat?

PBT is transdiagnostic, meaning it works across diagnostic categories. It has been applied to anxiety, depression, eating disorders, gambling, PTSD, substance use, couples distress, and chronic pain. The framework draws on evidence for targeting functional processes like emotion regulation, cognitive flexibility, and experiential avoidance.

Is there a process-based therapist near me in Pittsburgh?

Brian Nuckols, LPC-A, practices process-based therapy in Pittsburgh, PA. He built the Idiographic Clinical Network System (ICNS), a clinical tool that maps the unique network of processes maintaining each patient's disorder, enabling targeted interventions based on individual data.

What does a process-based therapy session look like?

In a PBT session, your therapist assesses which psychological processes are most active in your current distress and selects interventions that target those processes directly. This might mean working on emotion regulation one week, cognitive flexibility the next, and interpersonal effectiveness after that, depending on what the data shows is driving your symptoms.

Get Started

For questions about whether Process-Based Therapy is the right fit for your situation, or to schedule a consultation:

Schedule a consultation →