There’s a quiet crisis in how we think about psychotherapy. Over the past few decades, we’ve gotten very good at packaging therapies into neat boxes—Cognitive Behavioral Therapy, Dialectical Behavior Therapy, Compassion Focused Therapy, and on and on. Each with a manual or perhaps several. Each with a label. But in all that packaging, something important is getting lost.
Because when it comes down to what really drives change in therapy, it’s not the label on the box that matters. It’s not whether you used “the right” protocol. It’s whether you helped a person engage in a process that actually moves their life forward. To facilitate real transformations, we need to stop chasing protocols and start following processes.
Why Protocols Can Miss the Point
There’s a common assumption in clinical psychology: that if someone has a diagnosis—say, major depressive disorder—then we can match them to the “evidence-based” protocol for that diagnosis, follow the steps, and expect good outcomes. And to be fair, protocols have helped bring science into psychotherapy. They’ve given us a way to test treatments and show that therapy, in general, works.
But here’s one problem: the vast majority of people in therapy don’t show up with just one clean, textbook diagnosis. They come with messy, overlapping, deeply human struggles. For instance, what do we do when someone has anxiety and trauma and depression—and maybe a history of substance use and chronic pain too? Do we stack five protocols on top of each other?
And here’s another. The diagnosis does not really tell you what to do. It gives you some “what” answers, but virtually no “why” answers. That’s why not even one psychiatric syndrome has yet turned into a psychiatric disease.
And here is perhaps the worst problem of all. In the 40-50 years we’ve been following this agenda, the impact of therapy hasn’t grown! Something is wrong with that picture.
Finally we are begging to see what’s wrong. Because after decades of research, we now understand that different therapies succeed by targeting underlying biopsychosocial processes, and that these vary in their expression and combination person to person.
Let’s start with processes. A massive study I helped lead alongside Stefan Hofmann, Joe Ciarrochi, Baljinder Sahdra, and Fred Chin reviewed more than 54,000 studies to answer why therapy works, using strict mediational analysis. And after years of collaborative work, we finally got the results: psychological flexibility emerged as the most commonly effective pathway of change—more impactful than self-esteem, social support, or even the frequency of negative thoughts.
And we learned that with a small tweak we could modify and extend the Psychological flexibility, model to account for every replicated process of change.
That’s why protocol differences and therapy brands often matter less than we think. The most important question isn’t, “Which therapy brand are you using?” Instead, it’s, “Are you engaging the processes of change that matter most for this individual in their particular situation?”
What Are Change Processes and Why Do They Matter?
Change processes are the dynamic, evidence-based mechanisms that drive growth and overall well-being. They’re not about symptoms per se; they’re about how people relate to their internal experiences and navigate their lives. They include such things as acceptance, present-moment awareness, defusion (stepping back from thoughts), seeing yourself as more than your experiences, and committed action toward values. They include cognitive flexibility, taking care of your body, and healthy social attachment.
We can organize them all into a simple sentence. Life is asking you to learn to be more open, aware, and actively engaged in a meaningful life, while extending these to your relationships and your body. That’s it. Drop the mike. That’s a summary of 50 year of work by the entire field and hearly 45 years of work in Acceptance and Commitment Therapy (ACT).
Let’s break psychological flexibility down into its three core pillars:
- Awareness – Being present and noticing what’s happening, inside and out, from a witnessing perspective—without getting caught up in your experience.
- Openness – Allowing uncomfortable emotions and thoughts to be there without fighting them, without needing them to change before you take a step forward.
- Actively Engaged – Knowing what really matters to you and moving toward that, regardless of the noise in your mind or the pain you’re carrying.
Now extend those same processes to taking care of your body, and your relationships. For example, learn to sense what your body needs (healthy diet, sleep, exercise) and learn how to be more open to the emotions and thoughts of others (empathy and genuine understanding).
All therapies that work promote these skills – that’s why they work. That is true whether they’re called ACT, CBT, DBT, CFT, or ABCDEFG, They work because they modify change processes that matter. And the way they are helping people make long-lasting changes, is by targeting these processes in a way that fits each particular person.
How to Practice Process-Based Therapy
Process-Based Therapy (PBT) isn’t a new type therapy—it’s a shift in how we think about helping people change. Instead of asking, “Which treatment package do I apply to this diagnosis?” it asks, “What’s the process that’s keeping this person stuck—and how it be effectively changed to help them move forward?”
Whether you’re a therapist or someone seeking help, practicing process-based therapy means moving beyond protocols and focusing on the active ingredients that truly drive transformation. Here’s how to bring that mindset into practice.
If you’re a therapist, start by asking:
- What is your client trying to achieve? What do they want their life to be about?
- What processes are helping or hindering them in moving toward these goals or values?
- What small intervention can you use to shift one of those processes—today?
Then intervene with targeted precision: a metaphor, an experiential exercise, a simple moment of mindfulness, or something else entirely. You don’t need a 12-step protocol to shift a process. You need precision and presence. And importantly, you need to keep asking yourself: Is this helping this person become more psychologically flexible—more able to be present, open, and engaged with life—extending these skills to their relationship and their body?
And if you’re not a professional, but trying to make improvements in your own life, start by asking:
- What really matters to you in life—what kind of person do you want to be?
- What patterns in your thoughts, feelings, or actions keep pulling you away from that? Which are pulling you toward?
- And what’s one small thing you can do differently—right now—to move toward what matters?
When you stop trying to “fix” your thoughts or eliminate discomfort and instead start focusing on how to move forward with those experiences, something shifts. You start practicing the skill of living—not in ideal conditions, but in real ones.
The Future of Therapy Is Personal and Process-Based
Therapy isn’t about following a manual, but about cultivating change. And this happens through processes, not protocols. We now know that an extended form of psychological flexibility is the single most supported pathway of change in the science of psychotherapy, allowing you to show up, open up, and move forward—even when you’re struggling with anxiety, depression, addiction, or other kinds of physical or mental ailments.
If you’re a clinician, get curious about the individual in front of you, stay flexible, and follow the processes that matter. And if you’re someone seeking help, don’t worry quite so much about supposed disorders. Look more to the skills you need to become more flexible. Let’s stop asking what box we fit in, and instead start asking what helps us grow.
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