Why I Practice Process-Based Therapy: Moving Beyond Diagnosis-Driven Care

How a transdiagnostic, personalized approach to psychotherapy is changing the way we understand and treat anxiety, OCD, depression, and more

By Rachael St.Claire, PsyD Licensed Psychologist | St.Claire Psychology | Colorado Telehealth February 2026

When I first began my training in clinical psychology, the dominant model was clear: identify the diagnosis, select the corresponding protocol, deliver the manualized treatment. Anxiety? Try CBT with cognitive restructuring and graded exposure. Depression? Behavioral activation and thought records. OCD? ERP, administered with fidelity to the manual. The logic was elegant, and the research base was robust.

But over time — and through hundreds of hours sitting with real people navigating real suffering — I began to notice the limitations of this framework. Not because the treatments didn't work (they often did), but because the model itself was incomplete. It assumed that a diagnostic label tells us enough about a person to select the right intervention. In practice, it frequently doesn't.

This is why I now practice Process-Based Therapy, or PBT — a framework that has fundamentally reshaped how I understand psychological suffering, how I conceptualize my clients, and how I make clinical decisions in the room. In this post, I want to explain what PBT is, where it came from, and why I believe it represents an important evolution in evidence-based psychotherapy.

The Problem PBT Was Designed to Solve

To understand PBT, it helps to understand the problem it addresses. The dominant model of psychotherapy over the past several decades has been what researchers call the "protocol-for-syndrome" approach: match a treatment manual to a DSM diagnosis, and apply it accordingly.

This model produced enormous advances. Randomized controlled trials demonstrated that specific psychotherapies could be as effective as — and often more durable than — pharmacological interventions for many conditions. The credibility of psychotherapy as a scientific discipline grew substantially as a result.

But as the evidence base matured, certain uncomfortable patterns emerged. First, the "Dodo Bird verdict" — a now-famous finding suggesting that different psychotherapy approaches tend to produce roughly equivalent outcomes — raised the question of whether the specific techniques in any given protocol were truly the active ingredients, or whether something else was doing the heavy lifting. Second, comorbidity proved to be the rule rather than the exception: most people presenting for therapy meet criteria for more than one diagnosis, making the clean "one protocol per diagnosis" model difficult to apply. Third, dismantling studies (which test the individual components of multicomponent treatments) often failed to show that adding specific technique modules improved outcomes beyond the foundational elements of therapy.

These converging lines of evidence pointed toward a provocative conclusion: the diagnostic label may not be the most useful unit of analysis for selecting interventions. Something more granular — more process-level — might be needed.

What Process-Based Therapy Actually Is

PBT, as articulated by Steven C. Hayes, Stefan G. Hofmann, and their collaborators, is a framework — not a technique. It does not replace existing evidence-based methods like ACT, CBT, ERP, DBT, or MBCT. Rather, it provides a coherent theoretical structure for understanding when, why, and for whom those methods work.

At its core, PBT proposes that psychological suffering is maintained by identifiable biopsychosocial processes — patterns of cognition, emotion, attention, motivation, behavior, and self-relation that interact dynamically within a person's life context. Rather than asking "What disorder does this person have?", PBT asks "What processes are functionally driving this person's difficulties, and what evidence-based procedures can shift those processes in a positive direction?"

This is a significant conceptual shift. Instead of treating anxiety as a monolithic entity that receives a standardized intervention, PBT invites the clinician to analyze the specific processes maintaining this particular person's anxiety: Is experiential avoidance the primary driver? Is it attentional rigidity? Cognitive fusion with threat appraisals? Disconnection from core values? Each of these calls for a different therapeutic response — even within the same diagnostic category.

The framework draws on what Hayes and Hofmann have termed the "extended evolutionary meta-model" (EEMM), which organizes psychological processes along dimensions of variation, selection, retention, and context-sensitivity. Without getting overly technical, the EEMM provides a multi-level, multi-dimensional map of human functioning that allows clinicians to identify which processes are stuck, which are flexible, and where intervention is most likely to produce cascading positive change.

From Protocols to Processes: What Changes in the Therapy Room

In practical terms, practicing from a PBT framework changes several things about how I approach clinical work.

First, assessment becomes more dynamic and functionally oriented. Rather than administering a symptom checklist and arriving at a categorical diagnosis, I'm constructing a process-based case conceptualization — a map of the interconnected patterns that sustain the client's difficulties. This might include experiential avoidance, rumination, self-as-content (rigid identification with negative self-narratives), values disconnection, interpersonal withdrawal, or attentional inflexibility. Importantly, these processes cut across diagnostic boundaries. The same process of experiential avoidance may be maintaining someone's anxiety, their depression, and their relationship difficulties simultaneously.

Second, intervention selection becomes more precise and personalized. Instead of delivering a fixed protocol in a fixed sequence, I draw from a repertoire of evidence-based procedures — exposure, cognitive defusion, behavioral activation, values clarification, mindfulness-based attention training, acceptance-based strategies, and others — based on which processes the functional analysis suggests are most central. Two clients with the same DSM diagnosis may receive notably different therapeutic experiences, because their underlying process profiles differ.

Third, treatment is iterative and responsive. Because the focus is on processes rather than checklists, I can continuously monitor whether the targeted processes are actually shifting and adjust accordingly. If cognitive defusion work isn't producing the expected flexibility, perhaps the issue is more fundamentally about attentional control, or about an unaddressed values conflict. The framework supports ongoing hypothesis-testing rather than rigid adherence to a predetermined sequence.

Why This Matters for People Seeking Therapy in Colorado

If you're reading this as someone considering therapy — particularly telehealth therapy here in Colorado — you might wonder what this means for you in concrete terms.

It means that when we work together, I'm not going to treat you as a diagnosis. I'm going to treat you as a whole person with a unique constellation of experiences, patterns, strengths, and struggles. Your anxiety may look very different from someone else's anxiety, and the work we do together should reflect that.

It means that the therapeutic approach won't be rigid. If a particular strategy isn't resonating or isn't producing the change we're targeting, we can adjust. PBT gives us a principled basis for that flexibility — it's not arbitrary eclecticism, but a theoretically grounded, evidence-informed way of tailoring treatment to the individual.

It also means that comorbidity isn't a complication — it's expected. Many of the adults I work with in my Colorado telehealth practice are navigating anxiety alongside depression, OCD alongside perfectionism, health anxiety alongside grief. A process-based framework handles this naturally, because it targets the mechanisms that cut across these experiences rather than treating each diagnosis as a separate problem requiring a separate protocol.

And it means that therapy doesn't have to feel like it was designed for someone else. One of the most common things I hear from new clients is that previous therapy "didn't quite fit." PBT was built to address exactly that concern — by designing the work around the person, not around the label.

The Evidence Base: Where PBT Stands

It's important to be transparent about where PBT is in its development. PBT is not a treatment that has been validated through RCTs in the same way that, say, ERP for OCD or CBT for panic disorder have been. It is a metatheoretical framework — a way of organizing and applying the evidence base, not a standalone protocol to be tested as such.

The strength of PBT lies in the fact that the individual processes it targets — psychological flexibility, cognitive defusion, behavioral activation, values-based action, attentional control, self-compassion, and others — each have substantial empirical support. What PBT adds is a principled method for selecting among these targets based on individual functional analysis, rather than diagnostic category.

The theoretical architecture has been articulated in peer-reviewed publications (notably Hayes & Hofmann, 2018, and the comprehensive volume Process-Based CBT, edited by Hayes & Hofmann, 2018). Ongoing research continues to examine how process-based case conceptualization influences clinical outcomes, and early data is promising.

As a clinician, I consider PBT the most intellectually coherent and clinically useful framework available for integrating the diverse tools of modern evidence-based psychotherapy. But I hold that view with appropriate epistemic humility — it's a developing framework, and the field will continue to refine it.

What PBT Is Not

A few clarifications that may be useful, particularly for readers with clinical backgrounds:

PBT is not a rejection of manualized treatments. If a client presents with classic OCD and the functional analysis points clearly toward exposure and response prevention as the central mechanism of change, I will deliver ERP. PBT doesn't ask us to abandon what works — it provides a framework for understanding why it works and how to adapt when the standard approach falls short.

PBT is not eclectic in the pejorative sense. Eclecticism without a guiding framework risks becoming an incoherent mixture of techniques driven by clinical intuition alone. PBT is explicitly integrative — it provides a theoretical basis for selecting interventions across modalities.

PBT is not anti-diagnosis. The DSM has clear utility for communication, research, insurance, and epidemiology. What PBT challenges is the assumption that diagnostic categories are the optimal unit for guiding treatment selection at the individual level.

And PBT is not a fixed endpoint. It is a living, evolving framework — one that I expect will continue to be refined as the science of psychotherapy advances.

Closing Thoughts

I chose to center my practice around PBT because, after years of clinical work and ongoing engagement with the research literature, it most closely reflects what I believe therapy should be: scientifically grounded, personally meaningful, functionally precise, and deeply respectful of the individual.

If you're an adult in Colorado exploring telehealth therapy for anxiety, OCD, depression, perfectionism, health anxiety, life transitions, or the general experience of being "high-functioning but struggling inside," I'd welcome the opportunity to talk with you about whether this approach might be a good fit.

You can schedule a free 15-minute consultation by emailing rachael.stclaire@hush.com or visiting the Appointments page on this site. I look forward to hearing from you.

About the Author

Rachael St.Claire, PsyD, is a licensed psychologist providing telehealth psychotherapy to adults throughout Colorado. Her practice integrates Process-Based Therapy (PBT), Acceptance and Commitment Therapy (ACT), Cognitive Behavioral Therapy (CBT), Exposure and Response Prevention (ERP), and other evidence-based modalities. She specializes in working with anxiety, OCD, depression, perfectionism, health anxiety, chronic illness, and life transitions.

Website: www.stclairepsychology.com

Schedule a free consultation: rachael.stclaire@hush.com