From technique-based to process-based
What changes in your work when you begin to think in terms of active processes, no longer in protocols.
A quiet shift seems to be underway in how we look at psychotherapy. For decades we have grouped techniques into packages — protocols — which we applied to specific disorders. CBT for depression, EMDR for PTSD, schema therapy for personality. An orderly system, which has brought much good.
But it also became clear that the system did not quite hold together. Many protocols work equally well for different disorders. Many patients improve despite receiving the "wrong" therapy. And within one protocol we often find great differences in what works and what does not work for which patient. The protocol-disorder coupling was less solid than we thought.
What remains, when the protocols fall away?
The question that is increasingly raised — by Steven Hayes and Stefan Hofmann, by Hans Eisenga, by the PCSP tradition — is: what then are the active processes at work in all those different therapies? And can we direct our interventions at those, rather than at the surface techniques that wrap them?
The list of such processes is being built up, but is by now reasonably consistent across different researchers. Attention regulation. Cognitive flexibility. Acceptance and defusion. Values clarification. Behavioural activation. Social reconnection. Body awareness. Emotion regulation. Mentalising. Self-compassion. Meaning-making.
What strikes one: these processes are not disorder-specific. They work in depression and in anxiety and in personality and in trauma — not in the same dosage, not in the same mix, but as the active "ingredient" behind very different protocols.
"One who works with complex systems needs trial-and-error, creativity and responsiveness. Not as weakness, but as a fitting answer to a system that does not let itself be nailed down."
What might change?
Suppose: in our training we no longer learned "which protocol for which disorder", but "which processes are active and how you can encourage them". That would train the psychotherapist of tomorrow differently.
Instead of protocol execution, she learns to identify with every patient which active processes are underused. With one patient that is attention regulation (she is caught in rumination). With another it is values clarification (he no longer knows where he wants to go). With a third it is behavioural activation (she has come to a complete stop).
The interventions then come from a much broader repertoire. Sometimes they are classical CBT, sometimes ACT, sometimes mindfulness, sometimes motivational interviewing, sometimes EMDR, sometimes simply a conversation about what would give her life content. The instrument follows the active process, not the other way around.
Three changes in the consulting room
First: more listening, longer looking. In process-based work one does not immediately know which processes are underused. One listens first — extensively, not to "take a history" but to be able to see what is needed here. Often it takes two, three, four sessions before the picture is clear. That is no waste. That is work.
Second: more dialogue, less delivery. What can work in a protocol — "today we are going to do cognitive restructuring" — works less well in a process-based treatment. The patient must think along. Which processes work for her? Which interventions fit what she wants to achieve here? Treatment becomes a joint investigation, not the delivery of a service.
Third: more attention to timing. Which active processes you wish to engage with depends on where the patient stands now. Someone who has just recognised her trauma needs different work than someone who has been sitting in the chair with it for three years. Someone right before a possible tipping (early warning signals!) needs different attention than someone who stands quietly on stable ground.
What this is not
Process-based work is not eclecticism. It is not "we do whatever feels right". It is based on a growing empirical foundation of what the active processes in psychotherapy are, and it calls for systematic thinking about which processes work where and why.
Nor is it a rejection of protocols. Many protocols are precisely good chains of active processes, for a specific group of patients in a specific phase. If such a protocol fits this patient, then it fits. It becomes problematic only when we apply it because-it-belongs-to-the-disorder, while in this patient quite different processes are underused.
And it is no call to give up all structure. Therapy needs structure — for the patient and for the clinician. But the structure follows from the active process, not from a descending list of sessions.
How to begin?
For those who are curious about this, we recommend three steps.
One: read Hayes & Hofmann's Process-based CBT (2018), or the shorter Beyond the DSM (2020). It is an accessible entry.
Two: begin with one patient for whom existing protocol thinking does not work. Ask yourself after every session: which active processes did I encourage today? Which did I leave aside?
Three: find colleagues. Process-based work demands more solo thinking than protocol work. A peer-supervision group in which one discusses cases with this framework is, for most people, the fastest way to become better at it. (For this reason we also have groups on this platform — more about that under Activities.)
From technique-based to process-based work is not a revolution, it is a recalibration. A return to what experienced clinicians were actually doing already, but now better grounded, better transferable, and better researchable. It is perhaps the most tangible way in which complexity thinking can change the work in the consulting room.