Beyond linear mediation: Toward a dynamic network approach to study treatment processes
Open accessAbstract
Few clinical scientists would disagree that more research is needed on the underlying mechanisms and processes of change in psychological therapies. In the dominant current approach, processes of change are studied through mediation. The study of mediation has been largely structured around a distinction between moderation and mediation first popularized by Baron and Kenny's (1986) seminal article, which is based on a nomothetic and cross-sectional framework. In this article, we argue that this approach is unable to adequately address change processes in psychological therapies, because it falsely assumes that treatment change is a linear, unidirectional, pauci-variate process and that the statistical assumptions are met to study processes of change in an individual using a nomothetic approach. In contrast, we propose that treatment is a dynamic process involving numerous variables that may form bi-directional and complex relationships that differ between individuals. Such relationships can best be studied using an individual dynamic network approach connected to nomothetic generalization methods that are based on a firm idiographic foundation. We argue that our proposal is available, viable, and can readily be integrated into existing research strategies. We further argue that adopting an individual dynamic network approach combined with experimental analyses will accelerate the study of treatment change processes, which is necessary as the field of evidence-based care moves toward a process-based model. We encourage future research to gather empirical evidence to examine this approach.
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Modeling downstream mechanisms will likely require complex approaches such as network analytic frameworks.
“Modeling downstream mechanisms will likely require complex approaches such as network analytic frameworks”
From Measuring the active elements of cognitive-behavioral therapies (2023) · cites this paper as Hofmann et al., 2020
The second important component of PBT is the personalization of treatment based on information about the individual network of the problem and matching interventions based on their effective components to the central node of the network.
“The second important component of PBT is the personalization of treatment based on (a) information about the individual network of the problem and (b) matching interventions based on their effective components to the central node of the network [10].”
From Process-based therapy vs. routine-CBT for difficult-to-treat mood and anxiety disorders: study protocol for a randomized controlled trial (2024) · cites this paper as [10]
Outcomes and processes of therapeutic change are likely to be different from person to person.
“both outcomes and processes of therapeutic change are likely to be different from person to person (Hofmann et al., 2020;Vlaeyen et al., 2020).”
From Acceptance and Commitment Therapy for women living with Vulvodynia: A single-case experimental design study of a treatment delivered online (2022) · cites this paper as Hofmann et al., 2020
Linear mediation models, as employed in this study, may not be suitable to capture the complexity of therapeutic processes.
“Linear mediation models, as employed in our study, may not be suitable to capture the complexity of therapeutic processes”
From Transdiagnostic Processes as Mediators of Change in an Internet-Delivered Intervention Based on the Unified Protocol (2022) · cites this paper as Hofmann et al., 2020
The relationship between outcome and mediator is dynamic, bidirectional, and non-linear.
“the relationship between outcome and mediator are dynamic, bidirectional, and non-linear (Hofmann etal., 2020)”
From Transdiagnostic Processes as Mediators of Change in an Internet-Delivered Intervention Based on the Unified Protocol (2022) · cites this paper as Hofmann et al., 2020
If only studies of mediation within randomized controlled trials are examined, more than 1,000 significant findings can be identified, encompassing more than 100 processes of change.
“If only studies of mediation within randomized controlled trials are examined, more than 1,000 significant findings can be identified, encompassing more than 100 processes of change 71 .”
From “Third-wave” cognitive and behavioral therapies and the emergence of a process-based approach to intervention in psychiatry (2021) · cites this paper as [71]
The Abstract identifies mediation analysis of randomized controlled trials as a principal approach to studying processes of change. But our copy does not give counts of significant findings or distinct processes; searches for the claimed figures and equivalent terms found no supporting passage. The available passages have no page numbers. (LLM, conf=0.72)
Experimental — accuracy not yet measuredMediators often have bidirectional and complex relationships that vary across individuals.
“Mediators often form bi-directional and complex relationships that differ between individuals (Hofmann, Curtiss, & Hayes, 2020).”
From A process-based approach to psychological diagnosis and treatment:The conceptual and treatment utility of an extended evolutionary meta model (2020) · cites this paper as Hofmann, Curtiss, & Hayes, 2020
There is a similar lack of progress for behavioural markers in guiding and individualizing behavioural treatments such as psychotherapy.
“A similar lack of progress has been noted for behavioural markers in guiding and individualizing behavioural treatments such as psychotherapy.33”
From Precision clinical trials: a framework for getting to precision medicine for neurobehavioural disorders (2021) · cites this paper as [33]
Neurobehavioural treatment response may not obey a dose-response curve; it could evolve in complex, nonlinear ways both acutely and in the longer term as patients' needs, preferences, psychosocial context and neurobiology change over time.
“However, neurobehavioural treatment response may not obey a dose–response curve; it could evolve in complex, nonlinear ways both acutely and in the longer term, as patients’ needs, preferences, psychosocial context and neurobiology change over time.33”
From Precision clinical trials: a framework for getting to precision medicine for neurobehavioural disorders (2021) · cites this paper as [33]
New statistical methods allow researchers to model the temporal dynamics of illness at an individual level.
“New statistical methods allow researchers to model the temporal dynamics of illness at an individual level.33,48,49”
From Precision clinical trials: a framework for getting to precision medicine for neurobehavioural disorders (2021) · cites this paper as [33]
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Inflammatory Exposure and Depression in Older Adults With Insomnia
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Heterogeneity in response to treatment across tinnitus phenotypes
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- Authors
- Hofmann, S. G., Curtiss, J. E., & Hayes, S. C.
- Affiliations
- Boston University (US)
- University of Nevada, Reno (US)
- Corresponding author
- Hofmann, Stefan G.
- Venue
- Clinical Psychology Review
- Publisher
- Elsevier BV
- Published
- 2020-03
- Volume
- 76
- Pages
- 101824
- ISSN
- 0272-7358 (ISSN-L)
- PMC
- PMC7137783
- OpenAlex
- W3000381339
- Cited by
- 232
- References
- 110
- Citations by year
- 2026: 25 · 2025: 37 · 2024: 52 · 2023: 31 · 2022: 35 · 2021: 34 · 2020: 18
- FWCI
- 2.32
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Clinical Psychology Review (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Mental Health
- Topics
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Mental Health Research Topics
- Physical Sciences › Mathematics › Statistics and Probability › Advanced Causal Inference Techniques
- Keywords
- treatment process, psychotherapy, mediation analysis, moderation, dynamic network model, individual differences, idiographic approach, mechanistic model, evidence-based care, mechanisms of change
- MeSH terms
- Humans, Psychotherapy
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