Process-Based Therapy (PBT) represents a significant shift in psychological treatment, moving away from rigid diagnostic categories and symptom-focused interventions toward a more individualized, dynamic, and flexible approach. At its core, PBT emphasizes understanding the underlying psychological processes that contribute to a person’s distress and well-being. A key aspect of PBT is its use in clinical case formulation, which allows therapists to develop tailored treatment plans based on the unique patterns of cognition, emotion, and behavior that sustain or alleviate a client's difficulties. In this blog, we explore how PBT is applied in clinical case formulation and why it is a powerful tool in modern psychotherapy.
The Role of Case Formulation in Process-Based Therapy
Case formulation is the process of organizing and making sense of a client’s difficulties by identifying key psychological processes at play. In traditional models, case formulation often revolves around diagnosing a disorder and applying a standard treatment protocol.
However, in PBT, formulation focuses on:
Identifying Psychological Processes: Instead of assigning a label, PBT maps out key processes such as cognitive rigidity, emotional avoidance, or interpersonal difficulties.
Understanding Contextual Factors: PBT considers the individual’s life circumstances, social environment, and personal history in shaping their struggles.
Assessing Functionality: It examines how thoughts, emotions, and behaviors interact dynamically, influencing psychological flexibility or inflexibility.
Tailoring Interventions: The therapist selects interventions that target the specific processes sustaining distress rather than applying a one-size-fits-all approach.
Steps in Process-Based Case Formulation
1. Gathering Comprehensive Client Information
The first step in PBT case formulation involves a detailed assessment of the client’s experiences, challenges, and psychological patterns. This includes:
Conducting structured and open-ended interviews.
Utilizing psychological flexibility measures (such as ACT-based tools).
Observing how a client’s behaviors align with or move away from their values.
2. Mapping Psychological Processes
Once the relevant information is collected, the therapist identifies and categorizes psychological processes that are maintaining distress. These can include:
Cognitive Processes: Rigid thinking, overgeneralization, excessive rumination.
Emotional Processes: Emotional suppression, avoidance, or heightened reactivity.
Behavioral Processes: Maladaptive coping strategies, patterns of avoidance or compulsions.
Interpersonal Processes: Difficulties in relationships, social withdrawal, unhelpful communication styles.
The therapist may use models such as the Extended Evolutionary Meta Model (EEMM) to conceptualize how these processes interact dynamically rather than as isolated symptoms.
3. Functional Analysis: Understanding the Why
PBT focuses on function rather than form—why a person engages in certain behaviors, rather than just what those behaviors are. Functional analysis helps determine:
What reinforces unhelpful behaviors?
How do psychological processes interact across different contexts?
What strategies has the client used, and how effective have they been?
4. Developing an Individualized Treatment Plan
Once key processes and their functions are identified, the therapist collaboratively develops a treatment plan that:
Targets maladaptive processes through interventions such as cognitive defusion, values clarification, and mindfulness.
Enhances psychological flexibility, enabling clients to adapt their responses in more effective ways.
Monitors and adjusts interventions based on real-time feedback rather than adhering to a rigid protocol.
Example of a PBT Case Formulation
Let’s consider a client, Alex, who experiences chronic anxiety that significantly impacts their daily life. Instead of diagnosing generalized anxiety disorder and prescribing a pre-set treatment, a PBT-informed therapist would:
Cognitive Processes:
Identifying the process: Alex engages in excessive worry, often predicting worst-case scenarios in everyday situations.
Understanding its function: This type of worry creates a false sense of preparedness and control, making it difficult for Alex to disengage.
Intervention: Teaching cognitive defusion techniques to help Alex separate themselves from their thoughts and reduce their impact.
Emotional Processes:
Identifying the process: Alex frequently suppresses emotions related to fear and uncertainty, leading to increased physiological tension.
Understanding its function: Emotional suppression allows Alex to avoid immediate distress but heightens long-term anxiety.
Intervention: Introducing mindfulness-based emotion regulation strategies to help Alex process and tolerate discomfort rather than avoiding it.
Behavioural Processes:
Identifying the process: Alex avoids social situations due to fear of judgment, reinforcing their anxiety over time.
Understanding its function: Avoidance provides temporary relief but prevents Alex from learning that social interactions are often safe and manageable.
Intervention: Implementing values-based exposure to gradually increase participation in meaningful social activities.
Interpersonal Processes:
Identifying the process: Alex engages in self-criticism and struggles with assertiveness in relationships.
Understanding its function: Self-criticism serves as a protective mechanism to prevent perceived failure or rejection but leads to low self-esteem.
Intervention: Encouraging self-compassion exercises and assertiveness training to help Alex develop healthier relationship dynamics.
By addressing each process in a targeted way, the therapist tailors interventions to Alex’s unique needs, rather than applying a standardised treatment protocol. This personalised approach enhances Alex’s psychological flexibility, allowing for long-term, sustainable change. Let’s consider a client experiencing chronic anxiety. Instead of diagnosing generalized anxiety disorder and prescribing a pre-set treatment, a PBT-informed therapist would:
Identify key processes: Excessive worry (cognitive inflexibility), avoidance of social situations (behavioral avoidance), and self-criticism (emotional regulation difficulty).
Explore the function of these behaviors: Worrying may give the illusion of control, avoidance may provide temporary relief, and self-criticism may be an attempt to prevent perceived failures.
Select targeted interventions: Teaching cognitive defusion to reduce the impact of worry, encouraging values-based exposure to social situations, and developing self-compassion strategies to counter self-criticism.
Why PBT Case Formulation Matters
PBT provides a flexible and effective way to conceptualize clinical cases, ensuring that therapy is tailored to each individual rather than dictated by diagnostic categories. By focusing on dynamic processes, therapists can better understand and intervene in the patterns that sustain distress while promoting meaningful change.
Integrating Evidence-Based Practices
PBT is designed to be a flexible and integrative framework, allowing therapists to draw from multiple therapeutic models to address the specific psychological processes contributing to a client's distress. This adaptability enables the creation of personalized treatment plans that are responsive to the unique needs of each individual.
PBT is not a standalone therapy but a "model of models," serving as a general approach to clinical assessment, conceptualization, and treatment. It encourages the integration of various evidence-based therapeutic models and theories, grounded in evolutionary science principles, to accommodate the diverse processes identified in clients (Hofmann & Hayes, 2019).
By focusing on core mediators and moderators based on testable theories, PBT moves beyond the traditional medical illness model. This approach allows therapists to select and adapt interventions from different therapeutic modalities—such as cognitive-behavioral therapy, acceptance and commitment therapy, or psychodynamic approaches—tailoring them to target the specific processes maintaining a client's distress (Fisher & Bosley, 2022). This integrative strategy ensures that therapy is not limited to a single theoretical perspective but is instead a dynamic and personalized process. By drawing from a diverse set of therapeutic tools, PBT enhances the potential for effective and meaningful change in clients' lives.
Conclusion
Process-Based Therapy offers a nuanced and individualized approach to psychotherapy by centering on the dynamic processes that contribute to mental health challenges. Through meticulous case formulation and the integration of evidence-based interventions, PBT provides a flexible and effective framework for fostering meaningful change in clients' lives.
References
Ciarrochi, J., Hayes, L. L., Sahdra, B. K., & Parker, P. D. (2020). Contextual positive psychology: Policy recommendations for implementing positive psychology into schools. Frontiers in Psychology, 11, 333. https://doi.org/10.3389/fpsyg.2020.00333
Fisher, A. J., & Bosley, H. G. (2022). A process-based approach to cognitive behavioral therapy. Frontiers in Psychology, 13, 1002849. https://doi.org/10.3389/fpsyg.2022.1002849
Hayes, S. C., Hofmann, S. G., & Ciarrochi, J. (2022). Process-based therapy: The science and core clinical competencies of psychological flexibility. Context Press.
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
Wilson, D. S., Hayes, S. C., Biglan, A., & Embry, D. D. (2019). Evolving the future: Toward a science of intentional change. Behavioral and Brain Sciences, 42, e52. https://doi.org/10.1017/S0140525X18002102
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