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A complex systems approach to the study of change in psychotherapy
Open accessAbstract
BACKGROUND: A growing body of research highlights the limitations of traditional methods for studying the process of change in psychotherapy. The science of complex systems offers a useful paradigm for studying patterns of psychopathology and the development of more functional patterns in psychotherapy. Some basic principles of change are presented from subdisciplines of complexity science that are particularly relevant to psychotherapy: dynamical systems theory, synergetics, and network theory. Two early warning signs of system transition that have been identified across sciences (critical fluctuations and critical slowing) are also described. The network destabilization and transition (NDT) model of therapeutic change is presented as a conceptual framework to import these principles to psychotherapy research and to suggest future research directions. DISCUSSION: A complex systems approach has a number of implications for psychotherapy research. We describe important design considerations, targets for research, and analytic tools that can be used to conduct this type of research. CONCLUSIONS: A complex systems approach to psychotherapy research is both viable and necessary to more fully capture the dynamics of human change processes. Research to date suggests that the process of change in psychotherapy can be nonlinear and that periods of increased variability and critical slowing might be early warning signals of transition in psychotherapy, as they are in other systems in nature. Psychotherapy research has been limited by small samples and infrequent assessment, but ambulatory and electronic methods now allow researchers to more fully realize the potential of concepts and methods from complexity science.
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“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 Hayes & Andrews, 2020
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“Our primary aim is to illustrate how the clinical implications of a complex systems approach, as we and others have proposed elsewhere [1, 2, 90, 91], relate to the three characteristics that we examined.”
BackgroundNetworks of Adversity in Childhood and Adolescence and Their Relationship to Adult Mental Health
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“Using this approach in psychopathology, instead of analysing individual parts of a mental health disorder (e.g., a specific symptom), we can look at different aspects of a disorder interacting and changing over time (Hayes & Andrews, 2020).”
MethodFried, E. I., Rieble, C., & Rieble, C. (2023) · Clinical Psychology in Europe · doi:10.32872/cpe.10075 · Cited by 64
“In clinical psychology and psychiatry, recent studies have demonstrated the potential utility of a systems approach for understanding mental health problems like depression (Hayes & Andrews, 2020; Lutz et al., 2018; Olthof et al., 2023; Robinaugh et al., 2020; Wichers, 2014).”
BackgroundImplications of the Network Theory for the Treatment of Mental Disorders
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Slow down and be critical before using early warning signals in psychopathology
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“…for those individuals, the process of depressive remission showed the nonlinearity one would expect from a dynamic system, particularly in the context of therapy (Hayes & Andrews, 2020; Hayes & Strauss, 1998; Heinzel et al., 2014; Schiepek, 2009; Shapiro, 2015; Strunk & Lichtwarck-Aschoff, 2019).”
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“Recognizing the intertwined nature of body, mind, and social environment enhances the effectiveness of therapeutic interventions, allowing for a deeper understanding of human change processes (Hayes & Andrews, 2020).”
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“Both assumptions are violated in psychological testing (Gomes et al., 2019) and in treatment research most of the time (Hayes et al., 2020).”
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“…whereas changes in the dynamic patterns can be understood as destabilizing the pathological attractor and developing new, more healthy patterns of functioning, switching from a pathological to a healthier attractor, or making minor adjustments to maladaptive patterns (Hayes & Andrews, 2020).”
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“The warning signals leading to this attracting state can thus be detected upstream (Hayes and Andrews, 2020).”
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“Consequently, an increasing number of researchers recommend conceptualizing such disorders (Cramer et al., 2016; Hayes and Andrews, 2020; Kenzie et al., 2017; van der Wal et al., 2021), including LOAD (Cohen et al., 2022; Pomorska and Ockene, 2017; Rollo et al., 2016; Tang et al., 2019) as emergent…”
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“The illustration is reminiscent of similar representations of attractor landscapes 48 , such as those used in psychotherapy research 30 . d , In all panels, the progression from left to right represents the second layer of complexity: the temporal dynamics inherent in the interactions between…”
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“…stability landscape metaphor has been frequently used in the literature of psychopathology, especially from the complex systems approach (Scheffer et al., 2018; van Bork et al., 2024; Hayes & Andrews, 2020; Olthof et al., 2023b), it has not been fully computed from estimated psychological networks.”
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“In each cluster, every anger node reinforces the other nodes within that cluster, a phenomenon akin to “ pathological attractor states ” as outlined by Hayes and Andrews (2020).”
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“…relating it to work in psychiatry and complex systems theory that casts the primary role of therapeutic intervention as disrupting so-called ‘stuck states’, wherein a cognitive system becomes rigidly trapped within a particular attractor state (Hayes & Andrews, 2020 ; Olthof et al., 2020).”
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“Predictors of change are meaningfully distinct from variables that correlate with or simply predict each other because they help to illuminate temporal patterns and potentially more impactful treatment targets (10,64,65).”
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“Complexity science can inform the field in terms of more sophisticated theories and analytic methods to discover how people change and how that can be facilitated (Hayes and Andrews, 2020; Hayes et al., 2022; Heino et al., 2022; Hofmann et al., 2020; Olthof et al., 2020).”
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“thinking, so that the Earth and its inhabitants can be encountered as the highly complex adaptive systems they are (Varela et al., 1991; Margulis and Sagan, 1995; Capra, 1997; Duncan, 2018; Fried and Robinaugh, 2020; Hayes and Andrews, 2020).”
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“…data analysis allow for sophisticated approaches to estimating change over time (e.g. Mund & Nestler, 2019), encompassing multiple outcome domains (e.g. Hayes & Andrews, 2020) and assessing the impact of many prognostic variables simultaneously via formalized theories (Haslbeck et al., 2022).”
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“Complex systems have shifted from reductionist analyses of component parts (agents) and simple linear change to the study of interconnected elements ([24], p.”
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“Giventhe dynamic nature of psychological therapy[11], co-design sessions with therapists during the development phase are important for implementing effective programmatic controls in virtual supporters.”
Eckes, T., & Nestler, S. (2023) · Clinical Psychological Science · doi:10.1177/21677026231165677 · Cited by 5
“Dynamic systems emerge when elements that behave in a self-organizing and nonlinear fashion interact in a way that creates system-specific patterns (DeRuiter et al., 2017; Gelo & Salvatore, 2016; Hayes & Andrews, 2020).”
BackgroundHulsmans, D. H. G., Otten, R., Poelen, E. A. P., van Vonderen, A., Daalmans, S., Hasselman, F., Olthof, M., & Lichtwarck‐Aschoff, A. (2024) · BMC Psychiatry · doi:10.1186/s12888-024-05836-7 · Cited by 7
“Figure 1A shows instability-induced change, in which an existing attractor destabilizes to the extent that there is no valley left to contain the ball, making the ball roll towards a new valley [11, 12, 32].”
BackgroundTrajectories of parent criticism across treatment for youth self‐harm
Aitken, M., Perquier, F., Park, B., Carvalho, D., Wright-Hughes, A. M., Cottrell, D. J., & Szatmári, P. (2025) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.14144 · Cited by 7
“Participating in therapy may change established parent – youth interaction patterns, creating opportunities for therapy effects (Hayes & Andrews, 2020).”
Bouwman, V., Mobach, L., Teachman, B. A., & Salemink, E. (2025) · Behaviour Research and Therapy · doi:10.1016/j.brat.2025.104685 · Cited by 4
A Narrative Identity Perspective on Mechanisms of Change in Imagery Rescripting
Çili, S., & Stopa, L. L. (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2021.636071 · Cited by 5
Cane, T. P. C., Newton, P. D., & Foster, J. (2022) · Advances in Dual Diagnosis · doi:10.1108/add-12-2021-0019 · Cited by 4
Prediction of depression onset and development based on network analysis
Weixia, Z., Min, X., Tiantian, Y., Cheng, W., & Shubin, S. (2023) · Advances in Psychological Science · doi:10.3724/sp.j.1042.2023.02129 · Cited by 4
Cui, J., Olthof, M., Hasselman, F., & Lichtwarck‐Aschoff, A. (2025) · BMC Psychiatry · doi:10.1186/s12888-025-06688-5 · Cited by 4
“The destabilization of the unhealthy phase, which corresponds to the loosening of undesirable cognitive, affective, or behavioral patterns [12], then functions as a mechanism for the sudden gain toward a healthier phase.”
InfluentialFeyaerts, J., Brar, P. S., Sass, L. A., & Nelson, B. (2025) · The Lancet Psychiatry · doi:10.1016/s2215-0366(25)00244-5 · Cited by 3
Seizer, L., Kratzer, L., Löchner, J., Schöller, H. J., Aichhorn, W., & Schiepek, G. K. (2026) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.70222 · Cited by 3
“This pattern resonates with dynamic systems perspectives that conceptualize improvement as the emergence of new attractor states after periods of instability (Hayes and Andrews 2020; G. Schiepek et al. 2020).”
Driessen, J., Goekoop, R., Voerman, S. A., Mulder, A., Verhaar, M., Bos, J. H., Glas, G. G., & van den Berg, D. P. G. (2026) · Clinical Psychological Science · doi:10.1177/21677026251414040 · Cited by 3
Bernardi, R., & Eidlin, M. (2025) · The Psychoanalytic Quarterly · doi:10.1080/00332828.2025.2518927 · Cited by 3
Echterhoff, J., Kriston, L., Klein, J. P., Härter, M. C., Schramm, E., & Schumacher, L. (2024) · Psychotherapy Research · doi:10.1080/10503307.2024.2320349 · Cited by 3
“A first step in understanding potential mechanisms of change is to investigate whether the treatment had effects on the postulated mediators of a treatment and whether these postulated mediators impacted, in turn, relevant symptoms (Hayes & Andrews, 2020).”
Bos, F. M., Schreuder, M. J., George, S. V., Doornbos, B., Bruggeman, R., van der Krieke, L., Haarman, B. C. M., Wichers, M., & Snippe, E. (2021) · doi:10.31234/osf.io/v5b7t · Cited by 3
A unified pathogenic hypothesis for mental disorders based on schismogenesis
Garcı́a-Toro, M., & Gómez-Juanes, R. (2025) · Biosystems · doi:10.1016/j.biosystems.2025.105431 · Cited by 4
Darnell, B. C., Benfer, N., & Litz, B. T. (2025) · Clinical Psychology Review · doi:10.1016/j.cpr.2025.102671 · Cited by 2
Ngabo-Woods, H., Dunai, L., & Verdú, I. S. (2025) · Applied Sciences · doi:10.3390/app152312524 · Cited by 2
The Future of the Biopsychosocial Model: Toward a Transdisciplinary Systems Science of Mental Health
Robinaugh, D. J., Blanken, T. F., Bridger, E. K., Casamento‐Moran, A., de Ron, J., Henry, T. R., Hoekstra, R. H. A., Stratis, G., van de Leemput, I. A., van Nes, E. H., et al. (2026) · Clinical Psychological Science · doi:10.1177/21677026261435464 · Cited by 6
“…the notion that mental disorders emerge from complex systems of interacting components has seen a resurgence of interest (e.g., Borsboom, 2017; Hayes & Andrews, 2020; Nelson et al., 2017; Olthof et al., 2023; Schiepek & Pincus, 2023), and researchers collaborating across ecology, psychiatry,…”
A Multimodal Framework for Prognostic Modelling of Mental Health Treatment and Recovery Trajectories
Ngabo-Woods, H., Dunai, L., Verdú, I. S., & Sui, L. (2026) · Applied Sciences · doi:10.3390/app16020763 · Cited by 2
Mikkonen, K., Lintula, S. J., Rosenström, T. H., Lahti, J. M. T., Helminen, E.-E., Saarni, S. I., & Saarni, S. E. (2026) · Journal of Affective Disorders · doi:10.1016/j.jad.2026.121225 · Cited by 2
A topological data analysis method for revealing dynamic changes in psychotherapy microprocesses
Luo, X., & Zhang, M. (2026) · Frontiers in Psychology · doi:10.3389/fpsyg.2025.1711782 · Cited by 2
“Such saddle-driven dynamics are rarely examined in psychotherapy literature [see recent reviews by Hayes and Andrews (2020), and Klocek et al. (2024)], while continue to gain attention in other domains such as neuroscience (Kelso, 2012; Tognoli and Kelso, 2014; Hancock et al., 2025).”
Pham, T. D. (2021) · International Conference on Electrical, Computer and Energy Technologies (ICECET) · doi:10.1109/icecet52533.2021.9698467 · Cited by 2
“Based on this hypothesis, the theory of chaos and methods for nonlinear data analysis of complex systems have been applied for studying mood disorders and psychotherapy [5], [6].”
BackgroundThe subject-environment interplay between runners from different Brazilian macro-regions
Thuany, M., Bandeira, P. F. R., Vieira, D. A., Weiss, K., Knechtle, B., & Gomes, T. N. (2023) · Frontiers in Psychology · doi:10.3389/fpsyg.2023.1134797 · Cited by 3
“, 2022), psychology (Medin, 2017; Hayes and Andrews, 2020), and sports science”
BackgroundBooth, N., McConnell, T., Tully, M. A., Hamill, R., & Best, P. (2024) · Mental Health and Digital Technologies · doi:10.1108/mhdt-11-2023-0002 · Cited by 4
Kroemeke, A., Dudek, J. E., Kijowska, M., Owen, R., & Sobczyk‐Kruszelnicka, M. (2024) · Trials · doi:10.1186/s13063-024-08235-1 · Cited by 2
“The latter assumes that an intervention transforms the connectivity of the networks of intervention goals, the outcome of the intervention, and the connections between the two networks [35, 36].”
BackgroundComparing two major approaches to unifying psychology: Different goals, different outcomes
Young, G. C. (2024) · Current Psychology · doi:10.1007/s12144-024-06838-0 · Cited by 2
“In terms of the research program required to test the cur - rent model, the article gives one example related to sys - tems theory, following Gelo and Salvatore ( 2016), Hayes and Andrews ( 2020), Hofmann et al. (2020 ), and Schiepek and Pincus (2023 ).”
The Evolution of Parenting: Styles or Principles?
Friggieri, J., & Ellul, D. B. (2025) · Education and human development · doi:10.5772/intechopen.1008384 · Cited by 2
Systemische (Psychotherapie-)Forschung
Ochs, M. (2024) · Springer eBooks · doi:10.1007/978-3-662-64728-8_7 · Cited by 2
Preventive Mental Health Care: A Complex Systems Framework for Ambient Smart EnvironmentsPreprint
White, B. P., & Hipólito, I. (2023) · PsyArXiv (OSF Preprints) · doi:10.31234/osf.io/etsu4 · Cited by 3
Mind as “E”nteraction: Towards the Complexity HypothesisPreprint
Hipólito, I., van Geert, P. L. C., & Pessoa, L. (2023) · doi:10.31234/osf.io/2dtp6 · Cited by 2
Cui, J., Hasselman, F., Olthof, M., & Lichtwarck‐Aschoff, A. (2024) · PsyArXiv (OSF Preprints) · doi:10.31234/osf.io/b68wh · Cited by 2
Farahani, H., Blagojević, M., Azadfallah, P., Watson, P., Esrafilian, F., & Saljoughi, S. (2023) · Springer eBooks · doi:10.1007/978-3-031-31172-7_4 · Cited by 1
Otaif, F. A., & Asiri, A. (2025) · Multimodal Communication · doi:10.1515/mc-2024-0080 · Cited by 1
Psychodynamic psychotherapists’ perceptions of change: A phenomenological analysis
Antichi, L., Biondi, B., Giannini, M., & Grotto, R. L. (2025) · Psychotherapy Research · doi:10.1080/10503307.2025.2535564 · Cited by 1
“Research suggests that change often happens nonli-nearly, through sudden shifts or early rapid gains (Hayes et al., 2005; Hayes & Andrews, 2020; Tang & DeRubeis, 1999), which challenges models that assume steady progression.”
Pacing in New York City Marathon: a tracking approach
Thuany, M., Weiss, K., Villiger, E., Scheer, V., Gomes, T. N., Čuk, I., Andrade, M. S., Nikolaidis, P. Τ., Rosemann, T. J., & Knechtle, B. (2025) · Sport Sciences for Health · doi:10.1007/s11332-025-01549-w · Cited by 1
“Stability, change, and predictability are important facets of tracking, having been primordially studied in the context of motor behavior [20] and physical activity [19, 21].”
Cheng, F., Ma, Z., & Zeng, C. (2025) · Physica A Statistical Mechanics and its Applications · doi:10.1016/j.physa.2025.131170 · Cited by 1
Metadata
- Authors
- Hayes, A. M., & Andrews, L. A.
- Affiliations
- University of Delaware (US)
- Corresponding author
- Hayes, Adele M.
- Venue
- BMC Medicine
- Published
- 2020-07-14
- Volume
- 18
- Issue
- 1
- Pages
- 197-197
- ISSN
- 1741-7015 (ISSN-L)
- PMC
- PMC7359463
- OpenAlex
- W3042416448
- Cited by
- 149
- References
- 128
- Citations by year
- 2026: 25 · 2025: 31 · 2024: 25 · 2023: 33 · 2022: 22 · 2021: 11 · 2020: 2
- FWCI
- 6.81
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- BMC Medicine (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- Foundation for the National Institutes of Health (R21-MH062662, R01-MH086558)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Mental Health Research Topics
- Social Sciences › Education › Chaos, Complexity, and Education
- Keywords
- psychotherapeutic change, complex systems, dynamical systems theory, synergetics, network theory, critical slowing down, critical fluctuations, early warning indicators, system transition, nonlinear dynamics, psychopathology, ambulatory assessment, digital assessment
- MeSH terms
- Delivery of Health Care, Feedback, Humans, Psychotherapy
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