FORUM – “THIRD-WAVE” COGNITIVE BEHAVIORAL THERAPIES AS A STEP TOWARD PRECISION

MENTAL HEALTH CARE

“Third-wave” cognitive and behavioral therapies and the emergence

of a process-based approach to intervention in psychiatry
Steven C. Hayes1, Stefan G. Hofmann2,3
1
Department of Psychology, University of Nevada, Reno, NV, USA; 2Department of Psychological and Brain Sciences, Boston University, Boston, MA, USA; 3Department of Clini-
cal Psychology, Philipps-University Marburg, Marburg, Germany

For decades, cognitive and behavioral therapies (CBTs) have been tested in randomized controlled trials for specific psychiatric syndromes that were
assumed to represent expressions of latent diseases. Although these protocols were more effective as compared to psychological control condi-
tions, placebo treatments, and even active pharmacotherapies, further advancement in efficacy and dissemination has been inhibited by a
failure to focus on processes of change. This picture appears now to be evolving, due both to a collapse of the idea that mental disorders can be
classified into distinct, discrete categories, and to the more central attention given to processes of change in newer, so-called “third-wave” CBTs.
Here we review the context for this historic progress and evaluate the impact of these newer methods and models, not as protocols for treating
syndromes, but as ways of targeting an expanded range of processes of change. Five key features of “third-wave” therapies are underlined: a
focus on context and function; the view that new models and methods should build on other strands of CBT; a focus on broad and flexible
repertoires vs. an approach to signs and symptoms; applying processes to the clinician, not just the client; and expanding into more complex
issues historically more characteristic of humanistic, existential, analytic, or system-oriented approaches. We argue that these newer methods
can be considered in the context of an idiographic approach to process-based functional analysis. Psychological processes of change can be
organized into six dimensions: cognition, affect, attention, self, motivation and overt behavior. Several important processes of change combine
two or more of these dimensions. Tailoring intervention strategies to target the appropriate processes in a given individual would be a major
advance in psychiatry and an important step toward precision mental health care.

Key words: Process-based approach, cognitive behavioral therapy, third-wave therapies, processes of change, cognition, affect, attention, self,
motivation, overt behavior, precision mental health care

(World Psychiatry 2021;20:363–375)

For a field to progress over the long term, In the context of such challenges, it is idea that mental disorder can be classified
it needs to distinguish clearly its purposes wise for the field to refocus on its purpose. into distinct, discrete categories has been
from its strategies, so that new strategies If it does so, a large body of work is currently largely disproved. This transition has been
can be adopted when progress bogs down available to guide a new strategic approach. fostered by the so-called “third wave” of
in important areas. Such is the current situ- Intervention science in psychiatry has CBTs, which has raised a number of new
ation in modern mental health science and long sought an understanding of human underlying processes of change.
practice. By virtually every metric, the in- suffering that is based on the identifica- The field appears to be ready to move
cidence and prevalence of mental health tion of functionally important processes toward person-focused, evidence-based
problems is increasing worldwide, and our of etiology, development, maintenance care models that target core change pro-
approaches to producing improvement are and change, so as to help individual clients cesses based on testable theories instead
being challenged. Depression is now the achieve their goals through targeted and of latent disease entities that are moved by
number one cause of disability around the person-sensitive empirical methods. That evidence-based intervention protocols. If
world1 and rates of common mental health long-term purpose of scientific analysis we recognize the opportunity this moment
struggles have increased rapidly, especially has been implicit in the entire field of men- presents, an alternative analytic agenda is
among the young2. tal health over the decades, but the strate- available that can help our field, broadly
At the same time, biomedical treatments gies for getting there have differed across defined, to address its central purpose
are becoming more generic rather than disciplines and eras. At times these strate- more effectively.
more specific, and effect size improve- gies have disguised that ultimate purpose
ments for both psychosocial and biomedi- so thoroughly that researchers and provid-
cal interventions are minimal or absent3. ers have virtually forgotten why common THE LATENT DISEASE MODEL
Concern over side effects and unhealthy practices exist. OF PSYCHIATRY
physiological opponent processes fostered In this paper, we briefly review the his-
by the long-term use of common classes tory of the research and practical program In traditional psychiatric nosology, the
of psychoactive medications is growing4. of the cognitive and behavioral therapies i­ndividual’s presenting problems and ob-
Full genomic mapping of hundreds of (CBTs). Both the cognitive and behav- servable characteristics are organized into
thousands of persons is failing to support ioral wings of CBT began with a person- the “syndromes” that define his/her men-
a prominent role of genes in the etiology of specific process orientation, which has tal disorder. A syndrome is a set of signs
common mental conditions5. once again become a central focus as the (things the practitioner can see) and symp-

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toms (things people complain about) that ciples that were popular at the time, and no requirement to do the harder work of
tend to co-occur. As a set, they are seen as then linking categorization to those ideas. addressing private experiences over the
the possible expressions of a latent disease. The first two editions of the DSM were analysis of overt action. Metaphorically,
In other words, it is assumed that people heavily grounded in psychoanalytic the- Skinner opened the door to a scientific
likely share the same syndrome because ory. Until the DSM-III, it was assumed analysis of thoughts and feelings but gave
these sets of signs and symptoms are pro- that mental disorders would be shown no reason to walk through it.
duced by the same underlying etiological to be rooted in deep-seated conflicts that This “direct contingency” functional an-
causes, expressed in a characteristic mech- needed to be identified and resolved. At a alytic approach still exists in classic applied
anistic course over time, that can be altered meta-theoretical level, this view was fully behavior analysis, which today is largely
in known ways. This is reflected in our eve- consistent with a latent disease model. deployed for children with developmental
ryday language. For example, we often say Recently, psychodynamically-oriented disabilities. Early behavior therapists and
that a person “has depression” or that she clinicians have attempted to resurrect this behavior modifiers also added neo-behav-
is “suffering from an anxiety disorder”, just strategy with the notion that personality ioral principles drawn from associative or
as somebody “has the flu” or “is suffering disorders are at the core of all mental dis- social learning to Skinnerian operant prin-
from diabetes”. orders. To complement the DSM, psycho- ciples in an attempt to understand human
A syndromal strategy is topographical dynamically-oriented clinicians developed problems8-15. For example, theorists such
(in the sense that formal differences are the Psychodynamic Diagnostic Manual as Bandura argued that problems could
its proximal focus), but its purpose is func- (PDM-2)7. The goal is to describe people be based on the internalization of social
tional. The hope is that a focus on signs regarding their personality characteristics, norms or models9.
and symptoms will ultimately lead to use- the adequacy of their mental functioning, For both of these wings of behavior ther-
ful categories that will “carve nature at its and the patterns of symptom formation apy and modification (behavior analytic
joints” (a phrase that has been attributed they may show, with particular attention to and neo-behavioristic), traditional diagnos-
to Plato) by revealing disease entities with how they are experiencing these symptoms. tic categories were abstract concepts with
known processes of origin, development, The PDM-2 assumes that disorders are em- little known practical purpose. Instead,
maintenance and change. If these can be bedded in the client’s personality structure early behavior therapists believed that di-
identified, treatments can then target these and manifest in ways that vary with each agnosis should be linked to the individual
underlying disease processes in an increas- person’s functioning capacities. This too is application of scientifically well-established
ingly effective manner. fully consistent with a latent disease model. basic learning principles, leading to the se-
The “clinical utility” of diagnostic cat- lection of applied methods that were well-
egories is the pragmatic end state that in specified and empirically tested. This dual
principle validates the entire nosological THE ERA OF BEHAVIOR commitment is shown in Franks and Wil-
enterprise. The DSM-5 is clear about this THERAPY son’s famous definition of behavior therapy
ultimate goal: “The diagnosis of men- as consisting of interventions linked to
tal disorders should have clinical util- At the same time of the early days of the “operationally defined learning theory and
ity: it should help clinicians to determine DSM, an alternative model had considera- conformity to well established experimen-
prognosis, treatment plans, and potential ble impact. The first generation (or “wave”) tal paradigms”13.
treatment outcomes for their patients”6. of behavior therapy targeted psychological The divisions that existed within behav-
The assumption on which this strategy is problems largely based on the idiographic ior therapy at the time, especially between
based, however, is that collections of signs application of behavioral principles to neo-behaviorism and behavior analysis,
and symptoms reflect similar latent dis- specific cases. While agreeing that private were papered over by their common frus-
ease processes. If such processes exist but events were legitimate targets of scientific tration with the excesses of psychoanalytic
can lead to a myriad of forms, or a myriad analysis, Skinnerian behaviorism empha- thought and diagnostic strategies based
of processes can lead to similar forms, the sized observable and quantifiable behav- on it. Eysenck and Rachman once put it
syndromal strategy to reach clinical util- iors and their roles in altering the external this way: “There is no neurosis underlying
ity will likely fail, because in such cases environment, in part based on the belief the symptom, but merely the symptom
topography is poorly linked to underlying that overt behavior, thoughts and feelings itself. Get rid of the symptom… and you
processes. If processes of change are nor- were all reflections of the same sets of overt have eliminated the neurosis”14. Behavior
mal, they likewise cannot be adequately contingencies. It was argued, for example, therapists of all kinds took seriously the
construed as diseases, latent or otherwise. that the same aversive experiences could bottom line of changes in target behav-
Aging, for example, is not itself recognized lead to fear, thoughts regarding that pain- iors, not a questionable and constructed
as a disease, even though many processes ful history, or overt attempts to escape or disease entity15. Psychoanalytic fears of re-
of aging are known. avoid8. All of these psychological actions emergence of symptoms due to underlying
Earlier versions of the DSM pursued were believed to be reflections of the same conflicts14 largely failed to materialize16,17.
models of latent disease processes more history and thus, while all were argued Many of the learning principles that
directly by adopting theories and prin- to be scientifically legitimate8, there was were being applied had been identified

364 World Psychiatry 20:3 - October 2021

through intensive laboratory analysis of tion to turn to them. Just as behavior ther- Clark introduced his cognitive model by
small numbers of human or non-human apy began to open up to a wider range of referring to biological studies when he
subjects. This origin made it particularly processes that might account for psycho- wrote: “Paradoxically, the cognitive model
easy for either wing of behavior therapy to pathology, however, the DSM-III system of panic attacks is perhaps most easily in-
maintain its focus on the clinicians’ natural and the funding stream it released began troduced by discussing work which has
analytic agenda: application of knowledge to capture the attention of CBT research- focused on neurochemical and pharma-
to specific individuals with the purpose of ers and treatment developers. This had a cological approaches to the understanding
creating analyses and treatment plans that significant impact on the strategic vision of of panic”23.
would improve their outcomes. Early be- the tradition. Clark’s model conceptualized panic at-
havior therapy was always highly person- tacks as a consequence of the catastrophic
focused. Consider, for example, G.L. Paul’s misinterpretation of certain bodily sensa-
formulation of one of the most widely cited THE “SECOND WAVE” OF CBT tions, such as palpitations and breathless-
questions to guide psychological inter- ness23. An example of such a catastrophic
vention researchers: “What treatment, by Of all psychological treatment approach- misinterpretation would be that of a
whom, is most effective for this individual es, CBT aligned itself most closely to the healthy individual perceiving palpitations
with that specific problem, under which psychiatric nosology of the DSM/ICD, even as evidence of an impending heart attack.
set of circumstances, and how does it though the tradition from which it came The vicious cycle of the cognitive model
come about?”18. was idiographic and process-focused, with- suggests that various external (i.e., a super-
This question encouraged clinical re- out any assumption of latent diseases. This market) or internal (i.e., body sensations or
searchers to embrace a new scientific ap­ dialectic is still the source of considerable thoughts) stimuli trigger a state of appre-
proach to therapeutic intervention. Spe- controversy within CBT today. hension if they are perceived as threaten-
cifically, Paul’s question was intended to The core premise of the second era (or ing: “For example, if an individual believes
guide the field toward empirically sup- “second wave”) of CBT, as pioneered by that there is something wrong with his
ported treatments for specific psychologi- A.T. Beck and A. Ellis among others, held heart, he is unlikely to view the palpitation
cal problem areas that fit the needs of the that maladaptive cognitions contribute which triggers an attack as different from
individual based on known processes of to the maintenance of emotional distress the attack itself. Instead, he is likely to view
development, maintenance and change. and behavioral problems19,20. According both as aspects of the same thing – a heart
Unlike traditional psychiatric nosology, no to Beck’s model, these maladaptive cog- attack or near miss”23.
assumption of latent diseases was made – nitions include general beliefs, or sche- This model assumed that biological var­
the processes involved might be relatively mas, about the world, the self and the iables may contribute to an attack by trig-
normal and only their combination or future, giving rise to specific and automatic gering benign bodily fluctuations or inten-
contextual sensitivity may be pathological. thoughts in particular situations19. The ba- sifying fearful bodily sensations. Therefore,
Despite these differences in assumptions, it sic model posits that therapeutic strategies pharmacological treatments can be effec-
should not be missed that, at a deeper level, to change these maladaptive cognitions tive in reducing the frequency of panic at-
there was a shared interest in the identifi- lead to changes in emotional distress and tacks if they reduce the frequency of bodily
cation of clinically useful sets of processes problematic behaviors. fluctuations which can trigger panic, or if
that explained the origin, development, The cognitive approach allowed for al- they block the bodily sensations which ac-
maintenance and change of human suffer- ternative interpretations of biological mod- company anxiety. However, if the patient’s
ing. els, but a strength in the era of DSM was tendency to interpret bodily sensations
Franks and Wilson’s definition of the that they could be aligned with the medical catastrophically is not changed, discon-
field shows how heavily the early days of illness model. CBT followed psychiatry by tinuation of drug treatment is likely to be
behavior therapy relied on learning prin- designing specific protocols for syndromes associated with a high rate of relapse.
ciples in a narrower sense, especially those to be tested in randomized controlled tri- In broad terms, this model has empiri-
drawn from the animal laboratory13. That als. Mechanism and process research be- cal support, and cognitive content is in-
emphasis contained a strategic assump- came somewhat of an afterthought. CBT deed known to impact syndromal signs
tion that the behavioral principles which protocols became increasingly specific, and symptoms24. For example, panic pa-
applied to non-human animals comprised targeting specified DSM syndromes in line tients who were informed about the effects
a relatively adequate beginning set from with the latent disease model. of CO2 inhalation reported less anxiety and
which to construct functional analyses that A case in point is the story of panic fewer catastrophic thoughts than unin-
explained human suffering and human disorder. The original conceptualization formed individuals25. Furthermore, panic
prosperity. of this diagnosis was based on a medical patients who believed that they had con-
Well-developed theories of human cog- disease model assuming the existence of trol over the amount of CO2 they inhaled
nition and emotion were only just forming, distinct and mutually exclusive syndromes by turning an inoperative dial were less
but, by the late 1970s, the limitations of a with an inherently organic etiology and likely to panic than individuals who knew
direct contingency approach caused atten- specific treatment indications21,22. D.M. that they had no control over it26. The cog-

World Psychiatry 20:3 - October 2021 365

nitive package that was deployed for panic of expertise and led to difficulties for stu- ventions reflected differences in a priori
disorder based on these cognitive ideas dents and professionals to consider the assumptions and philosophy of science
was easy to standardize and manualize, progress of the field in a fully cohesive in such areas as units of analysis or truth
and there was relatively less need to link fashion. criteria37. For a contextualist, abstraction
specific treatment components to specific of a psychological action required under-
individual functional analysis. standing and appreciation of its history
More detailed and methodologically THE “THIRD WAVE” OF CBT and purpose, because the unit of analysis
­adequate research on precisely how change was always the “act-in-context”. For an el-
happens was put off to another day and, Underneath the surface, a set of con- emental realist, an action and its nature
as a result, CBT packages became more cerns gathered in the late 1990s and early could seemingly be appreciated alone and
focused on syndromes than processes. 2000s, that began to shine a light on the apart, much as a part taken from a dissem-
Because of diminished need for precision, need for both theoretical and philosophi- bled machine can be examined while sit-
there was less of an effort to weed out un- cal development within the behavioral and ting on the kitchen table. For instance, for
clear, inconsistent, and even contradictory cognitive tradition. These included empiri- a mechanist, “anxiety” could be viewed
theoretical and philosophical positions. cal issues such as the unexpected relative as a negative emotion based on its form,
The golden era of “protocols for syndromes” success of more narrowly focused and frequency or intensity; for a contextualist,
settled in, with a huge rise in CBT research overtly behavioral methods in compari- across a wide range of forms, frequency or
and funding for CBT laboratories. son to full CBT protocols, such as modern intensity, anxiety could be said to function
Close to 300 meta-analytic studies have forms of behavioral activation in the treat- negatively or positively with reference to its
examined CBT for a large range of DSM- ment of depression30; the unexpected context of occurrence40.
defined problems, with the strongest sup- results from large component analysis These different foundational assump-
port for anxiety disorders, somatoform studies of CBT31,32 in which cognitive com- tions of “third-wave” CBT methods pene-
disorders, bulimia, anger control prob- ponents were not found to be key to out- trated the clinical methods they produced
lems, and general stress27. There is much comes; and the unexplained response to and led to a rapid rise of new processes
to be proud of in this body of work. With its CBT protocols in early sessions, before pu- of change that focused on the function of
efficacy proven in many randomized con- tatively critical elements within the model cognition and emotion, over and above
trolled trials, often in comparison to the were presented33. They also included in- their form per se. For example, instead of
most effective medications, CBT helped consistent evidence of change processes trying to change the form, frequency, or sit-
countless people and saved many lives. using measures derived from traditional uational sensitivity of so-called “negative”
This has led to the implementation of cost- theoretical models34,35. In all of these ar- emotions or thoughts, as might be done
effective health care policies in many de- eas there were counterarguments to be in traditional CBT, “third-wave” methods
veloped countries around the world. made36, but the point is that matters that more frequently targeted the relationship
At the forefront currently is the UK ini- were considered well-settled within CBT of the client to his/her own experience. A
tiative called Improving Access to Psycho- were now unexpectedly under scrutiny. variety of process-oriented models and
logical Therapies (IAPT)28. This program At the same time, the dominance of el- sets of methods emerged within “third-
has been highly successful: not counting emental realist (or “mechanistic”) assump- wave” CBT, including dialectical behavio-
dropouts and refusals, about one in two tions were challenged by well-known CBT ral therapy (DBT)41, mindfulness-based
individuals using an IAPT program for de- researchers who took a more functional and cognitive therapy (MBCT)42, meta-cogni-
pression, anxiety or other mental health contextualistic philosophical stance37,38. tive therapy (MCT)43, functional analytic
problems recover, and as many as two in Most traditional CBT models assumed that psychotherapy (FAP)44, acceptance and
three show considerable improvements29. psychopathology and its treatment could be commitment therapy (ACT)45, modern
At the same time, the relative strength of thought of as being the result of sets of parts, forms of behavioral activation46, and sev-
outcome evidence allowed the assumption relations and forces that were ontologically eral others47.
that the role of cognitive and emotional preexisting, and thus needed to be modelled The initial shock of the “third wave” has
content is determinative in psychopathol- much as a machine would be modeled by a now passed37,47. CBT is currently a broad-
ogy to cover the open questions about the construction diagram. In contrast, some CBT er umbrella term that includes different
processes of change underlying CBT strat- researchers began to embrace constructiv- philosophical assumptions, targeted pro-
egies. Given the relative success and body ist assumptions – a more purely descriptive cesses, intervention approaches and phi-
of evidence for CBT, these open questions form of philosophical contextualism38,39 in losophies, living side by side. The more
seemed to be a small price to pay. which the very nature or meaning of events traditionally behaviorally oriented treat-
In the context of the hegemony of syn- could only be appreciated in their historical ments place a greater emphasis on history
dromal diagnosis, increasingly narrowly and situational context, and in the light of and context as it bears directly on overt ac-
focused interventional packages and pro- the purposes of scientific analysis itself. tion. The more cognitively oriented treat-
tocols were assembled within CBT. These It gradually became clear that some ments share the basic premise that mental
fostered ever more fractionated domains differences within the family of CBT inter- disorders and psychological distress are

366 World Psychiatry 20:3 - October 2021

maintained by cognitive content. “Third- clinically nonsensical. Rather, the modera- jor move toward treatment competencies
wave” methods come from both of these tion results suggest that evidence-based and processes of change in CBT. It makes
wings, but all focus on the person’s rela- therapists need to know about both types little empirical sense to focus on packages
tionship to his/her own experience. of models and methods. for syndromes if the actual sequence of
The amount of research now available The second shoe to hit the ground, af­ psychological changes that are function-
on “third-wave” methods is so extensive ter regular findings of moderation be- ally important to outcomes are not neces-
that it is not possible to characterize it ad- tween various CBT methods across eras sarily the putative mechanisms favored by
equately via individual studies, nor even and “waves”, has been a series of studies intervention developers and can be mod-
via individual meta-analyses. Just in the showing that the functionally important erated by such processes in unexpected
area of ACT, there are currently over 420 processes of change identified through ways. Traditional CBT developers might
randomized controlled trials48 and about mediational analysis sometimes differ be a bit startled to see that pain acceptance
80 meta-analyses49, covering a wide vari- and sometimes do not between these in- mediates outcomes in chronic pain, de-
ety of topics, from mental health to physi- tervention methods. Furthermore, these spite the fact that it was never targeted ex-
cal health, sport, social change, and high mediational findings do not always line up plicitly by the therapy they developed57,58.
performance. as expected. Similarly, an ACT developer might be
Some of the “third-wave” methods are We can stay with the series of studies puzzled to see that very high initial levels
as  good in terms of outcomes as gold- from UCLA to make this point. In a study of experiential avoidance in persons with
standard traditional CBT, but research has on the treatment of social anxiety disorder anxiety problems might suggest the use of
shown that such a “horse race” question with either ACT or traditional CBT, rapid traditional CBT over ACT, even though that
is the wrong one to ask, because different decreases in negative cognitions at the be- has always been a key target of ACT but not
moderators predict different outcomes. ginning of treatment mediated outcomes traditional CBT53.
Just as one cannot focus on main effects in both interventions, but an early rapid A consensus building process launched
statistically when significant interactions decrease in “experiential avoidance” (the by the Association for Behavioral and Cog­
are found, so too it is simply wrong to com- tendency to avoid difficult private experi- nitive Therapies is a clear example of this
pare packages in an overall fashion when ences) was a change mechanism specific change in focus within CBT. This associa-
moderation is regularly present. to ACT54. Cognitive defusion (i.e., the abil- tion brought together more than a dozen
Consider for example a series of studies ity to experience thoughts with a sense of professional societies to develop guidelines
from M. Craske’s laboratory at University distance from them, so as to diminish their for integrated education and training in
of California, Los Angeles (UCLA) compar- automatic behavioral impact) mediated cognitive and behavioral psychology59.
ing traditional CBT vs. ACT in people with worry, behavioral avoidance, and qual- Among their recommendations were the
anxiety disorders. In a study of CBT-based ity of life outcomes in both conditions, but key ideas that modern CBT needs to include
exposure versus ACT-based exposure50, more strongly predicted worry reductions clarity about philosophical assumptions;
the focus on “which package is better” ini- in CBT than in ACT55. understanding of processes of change; the
tially suggested that ACT was superior on This same pattern of distinction and ability to fit intervention methods to the
blind clinical ratings from post-treatment overlap has been shown in several studies needs of individuals; and competency in
to follow-up. Studies soon followed, how- that have examined the functionally im- delivering a wide variety of helpful ker-
ever, showing that this conclusion would portant pathways of change in CBT across nels across the various CBT wings, eras and
be misleading, because moderation analy- eras and “waves”. For example, cognitive “waves”.
ses showed a more complex picture. For defusion appears to mediate depression The lurching quality of “waves” comes
example, those with anxiety issues alone outcome for ACT more than for CBT56, from shifts in organizing assumptions that
did better with traditional CBT, while those while outcomes of traditional CBT for are too narrow: “processes of change can
with both anxiety and depression issues chronic pain are mediated by pain accept- be drawn heavily from non-human ani-
did better with ACT51. Several additional ance, even though this is not deliberately mals”, followed by “no, cognitive content is
studies by the same team identified other targeted by traditional CBT protocols57. key and is left out by that”, and then “no, the
significant moderators: for example, in In a multidisciplinary, multicomponent, relationship to experience is key and is left
a group of mixed anxiety disorders, ACT group-based CBT program for adults with out by a focus on content”. All of those as-
was better for those with initial high levels chronic pain, pre-treatment measures of sumptions contain some truth, but all are
of behavioral avoidance52, while CBT was psychological flexibility (the core process too limited for a mental health field-wide
better for persons with social phobia if they target of ACT) predicted ultimate out- effort to change the trajectory of evidence-
had very high levels of initial psychological comes, and change in each of the aspects based care. For example, all of these strate-
inflexibility53. of psychological flexibility measured in the gic assumptions in the generations of CBT
In the context of regular patterns of sig- study (acceptance, cognitive defusion, val- under-emphasize genetic, epigenetic and
nificant moderation, a question such as ues, committed action) separately medi- neurobiological processes, or the socio-
“which is better” between “second-wave” ated outcomes58. cultural processes, that are involved in hu-
and “third-wave” CBT is scientifically and Results such as these have caused a ma- man functioning.

World Psychiatry 20:3 - October 2021 367

 The slow progress of evidence-based From the cognitive wing, examples of to challenge and change specific thoughts,
intervention science, when measured this change include MBCT (“unlike CBT, thought recording is for decentering or de-
against the magnitude of human needs60, there is little emphasis in MBCT on chang- fusion purposes – noting thoughts so as to
demands an end to excessively narrow ing the content of thoughts; rather, the em- reduce their automatic impact. Likewise,
strategic assumptions that cause the field phasis is on changing awareness of and re- cognitive reappraisal is now focused more
of mental and behavioral health to lurch lationship to thoughts”62), and MCT (“MCT on cognitive flexibility and the utility of a
from one oversimplification to another. does not advocate challenging of negative variety of available constructions rather
While useful knowledge has emerged from automatic thoughts or traditional sche- than on noticing and eliminating most or
each of these eras, it is time to focus on a mas”63, because while “CBT is concerned all cognitive errors.
set of organizing principles that will allow with testing the validity of thoughts… MCT
what is most important in our knowledge is primarily concerned with modifying the
base to be used by all researchers and way in which thoughts are experienced and A focus on broad and flexible
practitioners interested in evidence-based regulated”63). repertoires vs. signs and symptoms
care. For that to happen, we need to recon- In more behaviorally rationalized meth-
sider what evidence-based care even is. ods, examples of this change include mod- It is characteristic of the more recent
An integrative cycle has begun that we ern behavioral activation (in which “in- methods that they have been relatively
argue may be able to carry not just CBT terventions address the function of nega- broadly focused. That is evident in the
forward, but the entire field of evidence- tive or ruminative thinking, in contrast to scope of their application and the breadth
based intervention science. Due in part to cognitive therapy’s emphasis on thought of their processes of change. The flexible
the churn of issues raised by “third-wave” content30”), and ACT (in which “the model and functional attentional focus of MCT,
methods, modern CBT has recently seen points to the context of verbal activity as the values work of ACT, the emotional reg-
an enormous increase in studies on pro- the key element, rather than the verbal ulation skills of DBT, the present focus of
cesses of change, especially in the form of content; it is not that people are thinking MBCT, can apply to virtually any life situ-
studies on treatment moderation and me- the wrong thing – the problem is… how the ation, not just narrowly conceived clinical
diation. Taken together, these findings lay verbal community supports its excessive pathology.
the foundation for a new way forward. use as a mode of behavioral regulation”64). In part as a result, a focus on specific
syndromes has rapidly broken down in
the last 15 years of CBT development, and
THE “THIRD WAVE” AND The view that new models and that in turn has set the stage for the transi-
PROCESSES OF CHANGE methods should build on other tion we are suggesting is taking place to a
strands of CBT process-based model of evidence-based
When the “third wave” of CBT was pro- intervention. CBT is rapidly becoming so
posed, it was in recognition of changes It is the job of a progressive field to carry “transdiagnostic” that even that term is
that were happening in all of the CBT everything that is useful forward as the no longer adequate. Indeed, “third-wave”
wings at the time35. Five key features were field develops. In the case of “third-wave” CBT seems to have particular affinity for
underlined61. Much in the same way that models, this was described as a core com- issues of resilience and positive growth, as
cognitive methods were assimilated into mitment to “transformation of these earlier much as the alleviation of problems65.
behavior therapy as a larger evolution of phases into a new, broader, more intercon-
the tradition, virtually all of these changes nected form; thus, while the implications
have been assimilated over the last 15 years may be revolutionary, the processes giving Applying processes to the clinician,
into the core of CBT writ large. They are rise to these developments are evolution- not just the client
worth reviewing because they arguably ary”37.
help form the foundation for the process- The newer methods of CBT have taken Almost all of the newer methods of CBT
based change that is now occurring. that idea to heart, and well-tested pro- take time to apply intervention to the prac-
cesses and kernels have been included as titioner, not just the client. In DBT, the task
steps forward were taken. Methods such “is to apply the therapy to one another, in
A focus on context and function as exposure, skills training, self-monitoring order to help each therapist stay within the
and behavioral homework were nearly therapy protocol”41. In MBCT, “perhaps
The newer methods of CBT have virtu- universally included. The larger framework the most important guiding principle is
ally all focused on principles of change that of CBT did change, however, as these pro- the instructor’s own personal mindful-
deal more with the context and function of cesses were assimilated. For example, ex- ness practice”66. In FAP, “in order to best
psychological events (e.g., thoughts, feel- posure is now more about values-based attend to the client’s experience, therapists
ings, and overt action) rather than their new learning than about emotional habit- first need to be in touch with their own”67.
content. uation per se. Similarly, rather than using it In ACT, “there is no fundamental distinc-

368 World Psychiatry 20:3 - October 2021

tion between the therapist and the client INTEGRATING THESE As we will emphasize, this step has in-
at the level of the processes that need to be SENSITIVITIES INTO PROCESS- deed been advanced powerfully by the
learned”68. BASED CBT “third-wave” methods and models, and
In part, this is because the methods are the strategic and assumptive features we
arguably more experiential, and there is As these core commitments have been have already reviewed, but, in a mature
the belief that you cannot teach what you given expression, a large body of evidence process-based approach, all empirically
cannot do. The other part of the picture has emerged on processes of change. These well-established processes and the inter-
is that these methods are based more on can be defined as theory-based, dynamic, vention kernels that move them need to be
how normal psychological processes can progressive, contextually bound, modifi- included in evidence-based care regard-
occur in ways that produce psychologi- able and multilevel mechanisms that oc- less of origin.
cal harm, and how these processes can cur in predictable, empirically established Empirically speaking, psychological
be rearranged to promote greater human sequences oriented toward desirable out- processes of change can be roughly organ-
prosperity. Empirically, that idea has been comes70. ized into six dimensions, which we will
borne out by evidence that “third-wave” These processes are theory-based in the consider in turn.
methods lead to positive psychological sense that they are associated with clear
outcomes for practitioners and trainees, scientific statements of relations among
not just their clients69. events that lead to testable predictions and Cognition
methods of influence; dynamic because
they may involve feedback loops and non- The newer forms of CBT have added
Expanding into more complex issues linear changes; progressive because they several processes of change in the dimen-
may need to be arranged in particular sion of cognition, but all of them focus
The newer forms of CBT have not hesi- sequences to reach the treatment or pre- on changing the relationship of thinker
tated to try to address a wide variety of vention goals; contextually bound and and thought. Particularly well-supported
complex human issues historically more modifiable so that they directly suggest change processes from newer forms of
characteristic of humanistic, existential, intervention kernels within the reach of CBT include cognitive defusion74 (which
analytic, or system-oriented approaches practitioners; and multilevel because is the ability to experience thoughts with
than CBT. For example, ACT addresses some processes supersede or are nested a sense of distance from them, so as to
issues of values and meaning making as within others. diminish their automatic behavioral im-
might occur more in existential therapy, The literature on processes of change is pact) and non-reactivity75,76 (which is al-
or of emotional openness and perspec- vast. Much of this is in the form of media- lowing cognitive or other experiences to
tive taking as might occur in humanistic tional analyses. If only studies of mediation come and go without reacting in an effort
or Gestalt approaches. FAP focuses on the within randomized controlled trials are ex- to change them). Both of these processes
qualities of the therapeutic alliance and amined, more than 1,000 significant find- alter the impact of human cognition by
how to use them to build more supportive ings can be identified, encompassing more changing the person’s relationship to his/
relationships, as might be expected in Ro- than 100 processes of change71. While the her own thoughts, rather than trying to
gerian psychology. DBT emphasizes inter- nomothetically-based pauci-variate, lin- change the form, frequency, or situational
personal validation very much as might be ear and unidirectional nature of mediation sensitivity of thought itself. As such, these
done in humanistic approaches. needs ultimately to be put aside in favor of are contextually focused processes, rather
Indeed, although the theoretical con- idiographic complex network analysis72, than being content focused – a key feature
cepts and ways of discussing these phe- that literature provides an empirical foun- of many “third-wave” processes.
nomena may differ, it would be hard to find dation for the steps that are now called for Our understanding of traditional more
any central issue in more depth-oriented in evidence-based care. content-oriented CBT cognitive constructs,
clinical work that is still left fully outside In what follows we summarize the lit- such as cognitive reappraisal77, rumina-
of the CBT tradition when all of its genera- erature on psychological processes of tion and worry78, catastrophizing79, and
tions, eras and “waves” are included. In a change in CBT, focusing largely on pro- dysfunctional thoughts80, have also been
few cases this breadth is occurring because cesses with mediational evidence. Our impacted by these newer concepts. For
modern CBT is simply borrowing methods, larger point is that, by their progressive example, it is not the mere appearance of
but in the majority of these cases it is more work on processes and procedures, the worry that is considered negative so much
that “third-wave” approaches are burrow- eras and “waves” of CBT have built a foun- as it is entanglement with worry. Similarly,
ing into issues that used to be ignored. ACT dation that now allows the entire mental it is not that reappraisal is a way to get to the
work focused on values choices, for exam- health field to move beyond protocols that “right thought” or to get rid of the “wrong
ple, is relatively unique technologically – are focused on syndromal entities into a thought”, but rather that there are a vari-
while being deeply resonant in its focus to new, idiographic form of process-based ety of thoughts available to guide action
other traditions. functional analysis73. and the client should notice and retain the

World Psychiatry 20:3 - October 2021 369

more functional ones. agement of more contextual emotional into evidence-based care, through such
A consensus appears to be emerging regulation strategies. concepts as an observing self or “self-as-
that what is most needed is enough healthy context”84, self-distancing97, decentering98,
psychological distance from thought, so or a sense of spirituality99.
that beliefs and cognitive constructions are Attention These senses of self are not defined by
not excessively entangling, either through evaluated content – indeed, in “third-wave”
avoidance and suppression, or attachment Traditional CBT did not have a rich con­ approaches, the conceptualized and evalu-
and rigid adoption81,82. In addition, what is ceptual language for the regulation of ated self is commonly viewed as an unhelp-
needed is enough cognitive flexibility81, so attention, with the exception of a small ful psychological process84. Rather, they
that an array of possibly useful construc- number of concepts, such as rumination refer to a sense of pure awareness or per-
tions are available in a given situation and and worry, that are attentional as well as spective taking, that affords or includes con-
the person can learn what is most useful in cognitive. In contrast, work on attention scious experience, but is not defined by its
that context. has been very dominantly evident in newer content.
forms of CBT. Almost all methods of “third- Of all the areas of development, this is
wave” CBT include forms of mindfulness- perhaps the most empirically difficult, be-
Affect based intervention or contemplative cause these deeper senses of self are diffi-
practice, and all of these methods thus in- cult to measure by self-report. A self that is
The newer forms of CBT have added a clude training in the flexible, fluid and vol- defined by pure awareness is not so much
variety of affective processes to those tar- untary control of attentional processes61,93. an object of reflection as it is a marker of
geted by traditional CBT. These new con- Such training can occur through contem- human consciousness per se99. Human
cepts all focus on how the person relates plative exercises, deliberated training in at- consciousness is too central a topic in the
to emotion, in such areas as the openness tentional control, guided imagery, or other history of psychology and behavioral sci-
to affect, the willingness to deepen expe- means of focusing on the now – shifting or ence to avoid, but its complexity can hard-
rience, and the importance of learning persisting in attention, and broadening or ly be overestimated. Nevertheless, studies
from emotional experience62. The most narrowing in attention, as the situation de- have shown the relevance of these “third-
frequently supported is acceptance82,84,85 mands. wave” processes to outcome100.
– the willingness to experience affect with- Mindfulness interventions impact a
out needless escape, avoidance or con- broad collection of change processes that
straint. Far from resignation, acceptance go far beyond attentional processes per Motivation
implies an active embrace of experience se94, and “mindfulness” as a term suffers
and learning from the content of affective from the wide varieties of measures and Motivation was a key focus in early
events. Other examples of newer affective perspectives that reflect its diverse history behavior therapy, especially in the form
processes are closely aligned with accept- of origin. Regardless, the link between at- of reinforcement and goal setting. These
ance, including self-compassion or self- tention and mindfulness is so strong that processes are still of known importance101,
kindness86, and distress tolerance87. sometimes “mindfulness” is used as a vir- along with such traditional motivational
The more content-focused concepts tual synonym for paying attention. concepts as intentions and expectations102.
found in traditional CBT, such as posi- The centrality of this dimension is shown The newer forms of CBT, especially ACT,
tive and negative affect88, loneliness89 and also by how these processes interact. For have added an emphasis on chosen values
hopelessness90, are still important clinical example, the shift from a focus on the as a key mediator of change84,103.
guides, especially when excessive in fre- content of thought to the process of think- The embrace of values choices as a mo-
quency or intensity, but the newer process- ing itself (as in cognitive defusion) is in tivational process needs to be seen in the
es expand on the clinical meaning of these part an attentional shift inside the cogni- context of the other dimensions added by
affective contents. For example, negative tive domain. Similar statements could be “third-wave” research and theory. For ex-
affect has been shown to be most behav- made about the “third-wave” processes of ample, greater emotional awareness and
iorally harmful when it kicks off processes change in affect, sense of self, or motiva- openness itself informs values choices, as
of suppression and avoidance91. When it tion. does greater cognitive and attentional flex-
does not, the capacity to notice and de- ibility.
scribe negative emotional experiences can
predict positive clinical trajectories even in Self
the presence of stressful emotions as de- Overt behavior
fined by their mere form92. These positive Self-regulation and self-management
trajectories may in turn reduce negative af- work began in the behavior therapy era95, A number of targeted skills have emerg­
fect over time, and thus to some degree the and continued in traditional CBT with ed in modern CBT, but these are often fo-
traditional content-focused processes may concepts such as self-efficacy96. The “third cused on other processes. For example,
also be long-term markers of the misman- wave” brought more spiritual senses of self DBT skills include methods of self-regula-

370 World Psychiatry 20:3 - October 2021

tion mediating outcomes of the therapy in In an increasingly diverse world, pro- tally add to the idionomic research base of
the area of suicidality104. ACT’s focus on a cesses at the socio-cultural level also can- process-driven complex network analyses
commitment to the creation of patterns of not be forgotten. Social processes that of psychological problems.
values-based actions has some empirical can vary between cultural groups, such as The idea of moving away from treat-
support105. forms of social support, or styles of fam- ing psychiatry labels toward treating the
However, the majority of known behav- ily functioning, are known empirically to individual patient by understanding the
ioral targets have roots in early behavior mediate outcomes112. Socially focused process-based complexity of his/her prob-
therapy, such as restriction of safety behav- processes from modern CBT are also lems and applying tailored intervention
iors, behavioral activation, problem-solv- important, including such issues as in- strategies is not new. The use of functional
ing, social skills, planning, or reductions in terpersonal compassion, perspective tak- analysis and case formulation is at the core
impulsivity106. ing, prosociality and empathy86. A more of the behavioral tradition73,115, but an em-
controversial but important focus is the pirical complex network approach based
therapeutic alliance, which mediates out- on ecological momentary assessment data
Cross-dimensional concepts comes across a variety of psychosocial drawn from the last 40 years of process-
interventions, but which also appears to based research is a substantial expansion,
Several of the important psychological have its impact in part because it promotes elaboration and further development of
processes of change combine two or more internalization of psychological processes this early tradition. In addition, it provides
of the above evolving dimensions. Self- of change such as acceptance, non-judg- a heuristically valuable model for a treat-
regulation arguably involves both overt ment, or maintaining a values focus113,114. ment-relevant classification system that is
behavior and sense of self. Mindfulness based on treatment processes.
involves affect, cognition and attention – We have identified the steps needed in
and in some models a transcendent sense ANALYZING PROCESSES OF such a process-based form of functional
of self. CHANGE analysis73. Unlike classical functional
Perhaps the prime example of such analysis, the steps begin with the consid-
clustered processes is psychological flex- Processes of change need to be studied eration of the features of the case in terms
ibility, which combines “third-wave” con- in a way that is consciously “idionomic” – of possible complex network formula-
cepts in each of the six above dimensions, i.e., that uses idiographic analysis for ulti- tions, identification of possible change
including emotional, cognitive and atten- mately nomothetic purposes72,115-117. This processes within the network, and collec-
tional flexibility, a perspective-taking sense approach encourages the clinician to ex- tion of higher temporal density longitu-
of self, values as a motivator, and construc- amine the functional connectivity between dinal measures to build out the network
tion of overt behavioral patterns of values- the various problems the client experiences empirically. Relevant treatment kernels
based habits. Meta-analyses have shown and the situations in which they occur, em- can then target the key elements of the cli-
that psychological flexibility is a common phasizing the use of processes of change to ent’s empirical network of experiences,
mediator of psychological change espe- characterize the development and main- actions, bio-physiological, socio-cultural,
cially with “third-wave” interventions such tenance of the client’s difficulties and the and situations features, that indicate key
as ACT107,108. limitations on his/her growth. processes of change idiographically over
For example, a person may respond to time. If the processes are altered in an ex-
historically produced social anxiety with pected direction, treatment can continue,
Processes of change at other level of social withdrawal in the service of avoid- and outcomes be assessed – which, if suc-
analysis ing feelings of inadequacy. Once we un- cessful, then allow idiographic patterns to
derstand the functional connections, we be identified and sorted into nomothetic
It is not possible to move to a process- can try to modify his/her maladaptive grouping, provided the individual pattern
based era staying entirely at the psycho- network by establishing greater emotional need not be distorted to do so. If targeted
logical level. At the bio-physiological level, openness, or increasing the likelihood of processes do not change, or expected
for example, changes in brain connectiv- compassionate social connection. An- outcomes do not follow, the cycle of pro-
ity have already been shown to mediate other person with very similar historically cess-based functional analysis could be
the impact of some cognitive interven- produced social anxiety may attempt to restarted.
tions. It is also known that processes of control negative social outcome by greater Studies have already suggested the em-
change such as emotional acceptance are vigilance to social threats, and increased pirical superiority of deploying evidence-
themselves mediated by the connectiv- rumination and worry. That person may based treatment modules or kernels to
ity strength between brain areas known to need work in increasing attentional con- target person-specific maladaptive pro-
relate to difficult emotional responses109. trol and training in reappraisal skills so as cesses of change, over global protocols tar-
Biologically relevant behavior change is to dampen ruminative cognitive habits. geting global syndromes118,119. Over time,
also known to be important in such area, These cases identify treatment relevant this recursive idionomic process-based
including diet, exercise and sleep110,111. functional analytic patterns that incremen- functional analytic strategy would build a

World Psychiatry 20:3 - October 2021 371

body of empirical nomothetic categories psychological struggles during the years ment change, thus ensuring the treatment
with known treatment utility120-122. from 1998 to 2007 (the most recent decade utility127 of the approach.
The field still would have to systematize with studies having reliable sample sizes). PBT marks an era that is more open,
this growing body of findings over time in In that time, the number of people using theoretically coherent, philosophically
a clinically accessible way that is not theo- only psychosocial change methods to ad- clear, broadly focused, and idiographic. In
retically narrow. That is a tall order, but dress their problems fell by nearly 50%, some ways this represents a throw-back to
it does not seem to be beyond our reach. while the number of those persons us- earlier days in CBT, but it is occurring now
Indeed, we have already proposed such a ing psychological approaches along with with new concepts, measures, empirical
system based on an extended evolutionary medications fell by about 30%. What shot approaches and analytic methods. Like a
account123. up? People using only medications. By walk up a spiral staircase, we cover previ-
2007 more than 60% of people with psy- ous ground, but in a more advanced posi-
chological conditions were using medica- tion.
CONCLUSIONS tion alone125. There is no body of science Many of these changes were greatly am­
that could justify such an unintended plified by the arrival of the “third wave”
As the controversy over the “third-wave” outcome of a latent disease construction. of CBT, but, for the sake of long-term pro-
passes into the rear-view mirror, contem- Indeed, global health specialists point out gress, it is important that the field not stay
porary CBT has become broader, more that, when this construction enters into there. All of the “waves” and eras of CBT,
flexible, more philosophically responsible, the developing world, care can deteriorate psychiatry, and evidence-based interven-
more process-focused and more com- rather than improve126. A new way forward tions more generally, have a place and a
mitted to fitting treatment methods to the is needed. role in the future that is unfolding. Iden-
needs of people. Data have increasingly Intervention science has arguably re­ach­ tifying processes of change has been the
emerged that reveal the wisdom of a pro- ed a tipping point as a new process-based implicit agenda of intervention science
cess approach61 as it applies to the under- paradigm is emerging70. This paradigm is from the beginning – it is time to make that
standing of traditional and newer-wave questioning the biomedicalization of hu- agenda the explicit core of our field.
CBT methods. man psychological suffering due to its poor
This does not argue that therapists can validity and clinical utility. The field ap-
be merely eclectic, because different mod- pears to be ready to move toward person-
REFERENCES
els may rely on contradictory philosophi- focused, evidence-based care models that
cal assumptions and theoretical concepts. target core change processes based on 1. World Health Organization. www.who.int/me-
diacentre/factsheets/fs369/en/.
Rather, therapists need to know how to testable theories, instead of latent disease 2. Mojtabai R, Olfson M, Han B. National trends in
identify and target central processes of entities that are moved by evidence-based the prevalence and treatment of depression in
change in a manner consistent with their intervention protocols. adolescents and young adults. Pediatrics 2016;
138:e20161878.
underlying evidence. This can only fully We believe that a process-based ap- 3. Kupfer DJ, First MB, Regier DA. A research agen-
happen if the field at large moves in a pro- proach represents a paradigm shift in da for DSM-V. Washington: American Psychiat-
cess-based direction. intervention science. The time is ripe for ric Association, 2002.
4. Andrews PW, Kornstein SG, Halberstadt LJ et al.
All of the strategic approaches to evi­ modern psychotherapy and intervention Blue again: perturbational effects of antidepres-
dence-based interventions have an ulti- science to focus on a new foundational sants suggest monoaminergic homeostasis in
mate purpose of understanding the pro- question that may be viewed as an ex- major depression. Front Psychol 2011;2:159.
5. Border R, Johnson EC, Evans LM et al. No sup-
cesses that account for the origin, develop- panded version of G.L. Paul’s original port for historical candidate gene or candidate
ment, maintenance and change of adaptive question: “What core biopsychosocial pro- gene-by-interaction hypotheses for major de-
or maladaptive human functioning. The cesses should be targeted with this client pression across multiple large samples. Am J
Psychiatry 2019;176:376-87.
assumption that mental problems reflect given this goal in this situation, and how 6. American Psychiatric Association. Diagnostic
the expression of a latent disease entity has can they most efficiently and effectively be and statistical manual of mental disorders, 5th
dominated psychiatric nosology, with the changed?”18. ed. Arlington: American Psychiatric Association,
2013.
distinction being one of tactics, whether Process-based therapy (PBT) is not a 7. Lingiardi V, Williams N. The psychodynamic di-
it is using psychoanalytic principles as in name for a new therapy – it is a name for agnostic manual – 2nd edition. New York: Guil-
the early days of the DSM, or identifying a new approach to evidence-based in- ford, 2017.
8. Skinner BF. The operational analysis of psycho-
syndromes, or developmental neurobiol- tervention science that uses contextually logical terms. Psychol Rev 1945;52:270-6.
ogy as in the case of the Research Domain specific and evidence-based processes in 9. Bandura A. Principles of behavior modification.
Criteria124. order to alleviate the suffering and pro- New York: Holt, Rinehart & Winston, 1969.
10. Bandura A. Social learning of moral judgments. J
This assumption appears to be inhibit- mote the prosperity of people. In contrast Pers Soc Psychol 1969;11:275-9.
ing the effective search for processes of to the protocol-for-syndromes approach, 11. Eysenck HJ. Classification and the problem of
change and has significantly altered mod- PBT targets theoretically derived and diagnosis. In: Eysenck HJ (ed). Handbook of
abnormal psychology. New York: Basic Books,
ern culture in dangerous ways. Consider empirically supported processes that are 1961:1-31.
people in the US who sought treatment for known to be responsible for positive treat- 12. Wolpe J. Psychotherapy by reciprocal inhibition.

372 World Psychiatry 20:3 - October 2021

 Redwood City: Stanford University Press, 1958. ioral treatment for alcohol dependence: a review mediators of treatment for social anxiety disor-
13. Franks CM, Wilson GT. Annual review of be- of evidence for its hypothesized mechanisms of der: comparing acceptance and commitment
havior therapy: theory and practice. New York: action. Addiction 2000;95:1475-90. therapy and cognitive-behavioral therapy. Behav
Brunner/Mazel, 1974. 36. Tang TZ, DeRubeis RJ. Reconsidering rapid early Ther 2014;45:664-77.
14. Eysenck HJ, Rachman S. The causes and cures of response in cognitive behavioral therapy for de- 55. Arch JJ, Wolizky-Taylor KB, Eifert GH et al. Lon-
neurosis. Boston: Knapp, 1965. pression. Clin Psychol 1999;6:283-8. gitudinal treatment mediation of traditional
15. Wolpe J, Rachman S. Psychoanalytic “evidence”: 37. Hayes SC. Acceptance and commitment thera- cognitive behavioral therapy and acceptance
a critique based on Freud’s case of little Hans. J py, relational frame theory, and the third wave of and commitment therapy for anxiety disorders.
Nerv Ment Dis 1960;131:135-48. behavioral and cognitive therapies. Behav Ther Behav Res Ther 2012;50:469-78.
16. Schraml W, Selg H. Behavior therapy and psy- 2004;35:639-65. 56. Zettle RD, Rains JC, Hayes SC. Processes of
choanalysis. Psyche 1966;29:529-46. 38. Jacobson NS. Can contextualism help? Behav change in acceptance and commitment therapy
17. Nurnberger JI, Hingtgen JN. Is symptom substi- Ther 1997;28:435-43. and cognitive therapy for depression: a media-
tution an important issue in behavior therapy? 39. Mahoney MJ. Continuing evolution of the cogni- tional reanalysis of Zettle and Rains (1989). Be-
Biol Psychiatry 1973;7:221-36. tive sciences and psychotherapies. In: Neimeyer hav Modif 2011;35:265-83.
18. Paul GL. Behavior modification research: design RA, Mahoney MJ (eds). Constructivism in psy- 57. Åkerblom S, Perrin S, Fischer MR et al. The me-
and tactics. In: Franks CM (ed). Behavior ther- chotherapy. Washington: American Psychologi- diating role of acceptance in multidisciplinary
apy: appraisal and status. New York: McGraw- cal Association, 1995:39-67. cognitive-behavioral therapy for chronic pain. J
Hill, 1969:29-62. 40. Meichenbaum D. Changing conceptions of Pain 2015;16:606-15.
19. Beck AT. Cognitive therapy: nature and relation cognitive behavior modification: retrospect and 58. Åkerblom S, Perrin S, Rivano Fischer M et al. Pre-
to behavior therapy. Behav Ther 1970;1:184-200. prospect. J Consult Clin Psychol 1993;61:202-4. dictors and mediators of outcome in cognitive
20. Ellis A. Reason and emotion in psychotherapy. 41. Linehan MM. Cognitive-behavioral treatment of behavioral therapy for chronic pain: the contri-
New York: Lyle Stuart, 1962. borderline personality disorder. New York: Guil- butions of psychological flexibility. J Behav Med
21. Klein DF. Delineation of two drug-responsive ford, 1993. 2021;44:111-22.
anxiety syndromes. Psychopharmacologia 1964; 42. Segal ZV, Williams JMG, Teasdale JT. Mindful- 59. Klepac RK, Ronan GF, Andrasik F et al. Guide-
5:397-408. ness-based cognitive therapy for depression: a lines for cognitive behavioral training within
22. Klein DF, Klein HM. The definition and psycho­ new approach to preventing relapse. New York: doctoral psychology programs in the United
pharmacology of spontaneous panic and phobia. Guilford, 2001. States: report of the inter-organizational task
In: Tyrer P (ed). Psychopharmacology of anxiety. 43. Wells A. Emotional disorders and metacogni- force on cognitive and behavioral psychology
Oxford: Oxford University Press, 1989:135-62. tion: innovative cognitive therapy. Chichester: doctoral education. Behav Ther 2012;43:687-97.
23. Clark DM. A cognitive approach to panic. Behav Wiley, 2000. 60. Kazdin AE, Blasé SL. Rebooting psychotherapy
Res Ther 1986;24:461-70. 44. Kohlenberg RJ, Tsai M. Functional analytic psy- research and practice to reduce the burden of
24. Hofmann SG. Toward a cognitive-behavioral chotherapy: creating intense and curative thera- mental illness. Perspect Psychol Sci 2011;6:21-
classification system for mental disorders. Behav peutic relationships. New York: Plenum, 1991. 37.
Ther 2014;45:576-87. 45. Hayes SC, Strosahl K, Wilson KG. Acceptance 61. Hayes SC, Villatte M, Levin M et al. Open, aware,
25. Rapee RM, Mattick R, Murrell E. Cognitive me- and commitment therapy: the process and prac- and active: contextual approaches as an emerg-
diation in the affective components of spontane- tice of mindful change, 2nd ed. New York: Guil- ing trend in the behavioral and cognitive thera-
ous panic attacks. J Behav Ther Exp Psychiatry ford, 2012. pies. Annu Rev Clin Psychol 2011;7:141-68.
1986;17:245-54. 46. Hayes SC, Follette VM, Linehan M (eds). Mind- 62. Segal ZV, Teasdale JD, Williams JMG. Mindful-
26. Sanderson WC, Rapee RM, Barlow DH. The in- fulness and acceptance: expanding the cognitive ness-based cognitive therapy: theoretical ration-
fluence of an illusion of control on panic attacks behavioral tradition. New York: Guilford, 2004. ale and empirical status. In: Hayes SC, Follette
induced via inhalation of 5.5% carbon dioxide- 47. Hayes SC. Acceptance and commitment thera- VM, Linehan MM (eds). Mindfulness and ac-
enriched air. Arch Gen Psychiatry 1989;46:157- py: towards a unified model of behavior change. ceptance: expanding the cognitive behavioral
62. World Psychiatry 2019;18:226-7. tradition. New York: Guilford, 2004:45-65.
27. Hofmann SG, Asnaani A, Vonk JJ et al. The effi- 48. Association for Contextual Behavioral Science. 63. Wells A. Meta-cognitive therapy for anxiety and
cacy of cognitive behavioral therapy: a review of ACT randomized controlled trials since 1986. depression. New York: Guilford, 2008.
meta-analyses. Cogn Ther Res 2012;36:427-40. https://contextualscience.org/ACT_Rand- 64. Hayes SC, Strosahl K, Wilson KG. Acceptance
28. National Health Service. Adult Improving Ac- omized_Controlled_Trials. and commitment therapy: an experiential ap-
cess to Psychological Therapies program, 2020. 49. Association for Contextual Behavioral Science. proach to behavior change. New York: Guilford,
https://www.england.nhs.uk/mental-health/ State of the ACT evidence. https://contextualsci- 1999.
adults/iapt/. ence.org/state_of_the_act_evidence. 65. Kashdan TB, Ciarrochi J. Mindfulness, accept-
29. National Health Service. IAPT at 10: achieve- 50. Arch JJ, Eifert GH, Davies C et al. Randomized ance, and positive psychology: the seven foun-
ments and challenges. https://www.england. clinical trial of cognitive behavioral therapy dations of well-being. Oakland: New Harbinger/
nhs.uk/blog/iapt-at-10-achievements-and- (CBT) versus acceptance and commitment ther- Context Press, 2013.
challenges/. apy (ACT) for mixed anxiety disorders. J Consult 66. Dimidjian S, Kleiber BV, Segal ZV. Mindfulness-
30. Jacobson NS, Martell CR, Dimidjian S. Behavioral Clin Psychol 2012;80:750-65. based cognitive therapy. In: Kazantzis N, Rei-
activation treatment for depression: returning to 51. Wolitzky-Taylor KB, Arch JJ, Rosenfield D et al. necke MA, Freeman A (eds). Cognitive and be-
contextual roots. Clin Psychol 2001;8:255-70. Moderators and non-specific predictors of treat­ havioral theories in clinical practice. New York:
31. Dimidjian S, Hollon SD, Dobson KS et al. Ran- ment outcome for anxiety disorders: a compari- Guilford, 2009:307-30.
domized trial of behavioral activation, cognitive son of cognitive behavioral therapy to acceptance 67. Kohlenberg RJ, Tsai M, Kanter JW. What is func­
therapy, and antidepressant medication in the and commitment therapy. J Consult Clin Psychol tional analytic psychotherapy. In: Tsai M, Kohlen­
acute treatment of adults with major depression. 2012;80:786-99. berg RJ, Kanter JW et al (eds). A guide to func-
J Consult Clin Psychol 2006;74:658-70. 52. Davies CD, Niles AN, Pittig A et al. Physiological tional analytic psychotherapy: awareness, cour-
32. Jacobson NS, Dobson KS, Truax PA et al. A com- and behavioral indices of emotion dysregulation age, love and behaviorism. New York: Springer,
ponent analysis of cognitive-behavioral treat- as predictors of outcome from cognitive behav- 2008:1-16.
ment for depression. J Consult Clin Psychol 1996; ioral therapy and acceptance and commitment 68. Pierson H, Hayes SC. Using acceptance and com­
64:295-304. therapy for anxiety. J Behav Ther Exp Psychiatry mitment therapy to empower the therapeutic
33. Ilardi SS, Craighead WE. The role of nonspecific 2015;46:35-43. relationship. In: Gilbert P, Leahy R (eds). The thera-
factors in cognitive-behavior therapy for depres- 53. Craske MG, Niles AN, Burklund LJ et al. Ran­ peutic relationship in cognitive behavior therapy.
sion. Clin Psychol 1994;1:138-56. domized controlled trial of cognitive behavioral London: Routledge, 2007:205-28.
34. Bieling PJ, Kuyken W. Is cognitive case formu- therapy and acceptance and commitment thera- 69. Dereix-Calonge I, Ruiz FJ, Sierra MA et al. Ac-
lation science or science fiction? Clin Psychol py for social phobia: outcomes and moderators. ceptance and commitment training focused on
2003;10:52-69. J Consult Clin Psychol 2014;82:1034-48. repetitive negative thinking for clinical psychol-
35. Morgenstern J, Longabaugh R. Cognitive-behav- 54. Niles AN, Burklund LJ, Arch JJ et al. Cognitive ogy trainees: a randomized controlled trial. J

World Psychiatry 20:3 - October 2021 373

 Contextual Behav Sci 2019;12:81-8. World Psychiatry 2020;19:51-2. mote mental health in university students. J Clin
70. Hofmann SG, Hayes SC. The future of interven- 86. Ong CW, Barney JL, Barrett TS et al. The role of Psychol 2020;76:929-51.
tion science: process-based therapy. Clin Psy- psychological inflexibility and self-compassion 104. Neacsiu AD, Rizvi SL, Linehan MM. Dialectical
chol Sci 2019;7:37-50. in acceptance and commitment therapy for clin­ behavior therapy skills use as a mediator and
71. Hayes SC, Ciarrochi J, Hofmann SG et al. How ical perfectionism. J Contextual Behav Sci 2019; outcome of treatment for borderline personality
change happens: what the world’s literature on 13:7-16. disorder. Behav Res Ther 2010;48:832-9.
the mediators of therapeutic change can teach 87. Farris SG, Leyro TM, Allan NP et al. Distress in- 105. Scott W, Hann KEJ, McCracken LM. A com-
us. Presented at the Evolution of Psychotherapy tolerance during smoking cessation treatment. prehensive examination of changes in psy-
Conference, Erickson Foundation, December Behav Res Ther 2016;85:33-42. chological flexibility following acceptance and
2020. 88. Schmidt M, Benzing V, Kamer M. Classroom- commitment therapy for chronic pain. J Con-
72. Hofmann SG, Curtiss JE, Hayes SC. Beyond based physical activity breaks and children’s temp Psychother 2016;46:139-48.
linear mediation: toward a dynamic network attention: cognitive engagement works. Front 106. Dietz LJ, Weinberg RJ, Brent DA et al. Family-
approach to study treatment processes. Clin Psy- Psychol 2016;7:1474. based interpersonal psychotherapy for de-
chol Rev 2020;76:101824. 89. Cleary EH, Stanton AL. Mediators of an Internet- pressed preadolescents: examining efficacy and
73. Hayes SC, Hofmann SG, Stanton CE. Process- based psychosocial intervention for women with potential treatment mechanisms. J Am Acad
based functional analysis can help behavioral breast cancer. Health Psychol 2015;34:477-85. Child Adolesc Psychiatry 2015;54:191-9.
science step up to the challenges of novelty: 90. Brent DA, Kolko DJ, Birmaher B et al. Predic- 107. Stockton D, Kellett S, Berrios R et al. Identifying
COVID-19 as an example. J Contextual Behav Sci tors of treatment efficacy in a clinical trial of the underlying mechanisms of change during
2020;18:128-45. three psychosocial treatments for adolescent Acceptance and Commitment Therapy (ACT):
74. Bach P, Gaudiano BA, Hayes SC et al. Accept- depression. J Am Acad Child Adolesc Psychiatry a systematic review of contemporary mediation
ance and commitment therapy for psychosis: 1998;37:906-14. studies. Behav Cogn Psychother 2019;47:332-62.
intent to treat hospitalization outcome and me- 91. Luoma JB, Pierce B, Levin ME. Experiential avoid- 108. Ren ZH, Zhao CX, Bian C et al. Mechanisms of
diation by believability. Psychosis 2013;5:166-74. ance and negative affect as predictors of daily the acceptance and commitment therapy: a
75. Garland EL, Gaylord SA, Palsson O et al. Thera- drinking. Psychol Addict Behav 2020;34:421-33. meta-analytic structural equation model. Acta
peutic mechanisms of a mindfulness-based 92. Shallcross AJ, Troy AS, Boland M et al. Let it be: Psychol Sin 2019:51:662-76.
treatment for IBS: effects on visceral sensitivity, accepting negative emotional experiences pre- 109. Eack SM, Newhill CE, Keshavan MS. Cognitive
catastrophizing, and affective processing of pain dicts decreased negative affect and depressive Enhancement Therapy improves resting-state
sensations. J Behav Med 2012;35:591-602. symptoms. Behav Res Ther 2010;48:921-9. functional connectivity in early course schizo-
76. Zou Y, Li P, Hofmann SG et al. The mediating role 93. Goldin PR, Morrison A, Jazaieri H et al. Group phrenia. J Soc Soc Work Res 2016:7;211-30.
of non-reactivity to mindfulness training and CBT versus MBSR for social anxiety disorder: a 110. Peltz JS, Daks JS, Rogge RD. Mediators of the as-
cognitive flexibility: a randomized controlled randomized controlled trial. J Consult Clin Psy- sociation between COVID-19-related stressors
trial. Front Psychol 2020;11:1053. chol 2016;84:427-37. and parents’ psychological flexibility and inflex-
77. Manne SL, Winkel G, Rubin S et al. Mediators 94. Duarte J, Pinto-Gouveia J. Mindfulness, self-com- ibility: the roles of perceived sleep quality and
of a coping and communication-enhancing passion and psychological inflexibility mediate energy. J Contextual Behav Sci 2020;17:168-76.
intervention and a supportive counseling inter- the effects of a mindfulness-based intervention 111. Firth J, Solmi M, Wootton RE et al. A meta-review
vention among women diagnosed with gyne­ in a sample of oncology nurses. J Contextual Be- of “lifestyle psychiatry”: the role of exercise,
cological cancers. J Consult Clin Psychol 2008; hav Sci 2017;6:125-33. smoking, diet and sleep in the prevention and
76:1034-45. 95. Tharpe RG, Wetzel RJ. Behavior modification in treatment of mental disorders. World Psychiatry
78. Topper M, Emmelkamp PM, Watkins E et al. the natural environment. Cambridge: Academic 2020;19:360-80.
Prevention of anxiety disorders and depression Press, 1969. 112. Acosta MC, Possemato K, Maisto SA et al. Web-
by targeting excessive worry and rumination in 96. Bandura A. Self-efficacy. In: Weiner IB, Craig- delivered CBT reduces heavy drinking in OEF-
adolescents and young adults: a randomized head WE (eds). The Corsini encyclopedia of psy- OIF veterans in primary care with symptomatic
controlled trial. Behav Res Ther 2017;90:123- chology. Hoboken: Wiley, 2010:1-3. substance use and PTSD. Behav Ther 2017;48:
36. 97. Petrova K, Nevarez MD, Waldinger RJ et al. Self- 262-76.
79. Smeets RJEM, Vlaeyen JWS, Kester ADM et al. distancing and avoidance mediate the links 113. Gifford EV, Kohlenberg B, Hayes SC et al. Does
Reduction of pain catastrophizing mediates the between trait mindfulness and responses to acceptance and relationship-focused behavior
outcome of both physical and cognitive-behav- emotional challenges. Mindfulness 2021;12:947- therapy contribute to bupropion outcomes? A
ioral treatment in chronic low back pain. J Pain 58. randomized controlled trial of FAP and ACT for
2006;7:261-71. 98. Fissler M, Winnebeck E, Schroeter T. An inves- smoking cessation. Behav Ther 2011;42:700-15.
80. Espie CA, Kyle SD, Miller CB et al. Attribution, tigation of the effects of brief mindfulness train- 114. Walser RD, Karlin BE, Trockel M et al. Training
cognition and psychopathology in persistent in- ing on self-reported interoceptive awareness, in and implementation of acceptance and com-
somnia disorder: outcome and mediation anal- the ability to decenter, and their role in the re- mitment therapy for depression in the Veterans
ysis from a randomized placebo-controlled trial duction of depressive symptoms. Mindfulness Health Administration: therapist and patient out­
of online cognitive behavioural therapy. Sleep 2016;7:1170-81. comes. Behav Res Ther 2013;51:555-63.
Med 2014;15:913-7. 99. Hayes SC. Making sense of spirituality. Behavior- 115. Hayes SC, Hofmann SG, Stanton CE et al. The role
81. Kashdan TB, Barrios V, Forsyth JP et al. Experi- ism 1984;12:99-110. of the individual in the coming era of process-
ential avoidance as a generalized psychologi- 100. Yu L, Norton S, McCracken LM. Change in “self- based therapy. Behav Res Ther 2019;117:40-53.
cal vulnerability: comparisons with coping and as-context” (“perspective-taking”) occurs in Ac- 116. Hofmann SG, Curtiss J, McNally RJ. A complex
emotion regulation strategies. Behav Res Ther ceptance and Commitment Therapy for people network perspective on clinical science. Per-
2006;9:1301-20. with chronic pain and is associated with im- spect Psychol Sci 2016;11:597-605.
82. Vowles KE, McCracken LA, Eccleston C. Patient proved functioning. J Pain 2017;18:664-72. 117. Molenaar PCM. On the implications of the clas-
functioning and catastrophizing in chronic pain: 101. Stacey FG, James EL, Chapman K et al. Social sical ergodic theorems: analysis of developmen-
the mediating effects of acceptance. Health Psy- cognitive theory mediators of physical activity tal processes has to focus on intra-individual
chol 2008;27:136-43. in a lifestyle program for cancer survivors and variation. Dev Psychobiol 2008;50:60-9.
83. Kalia V, Knauft K. Emotion regulation strate- carers: findings from the ENRICH randomized 118. Burke JD, Loeber R. Mechanisms of behavioral
gies modulate the effect of adverse childhood controlled trial. Int J Behav Nutr 2016;13:49. and affective treatment outcomes in a cognitive
experiences on perceived chronic stress with 102. Chatzisarantis NLD, Hagger MS. Effects of an behavioral intervention for boys. J Abnorm Child
implications for cognitive flexibility. PLoS One intervention based on self-determination theory Psychol 2016;44:179-89.
2020;15:0235412. on self-reported leisure-time physical activity 119. Chorpita BF, Weisz JR, Daleiden EL et al. Long-
84. Hayes SC. A liberated mind: how to pivot to- participation. Psychol Health 2009;24:29-48. term outcomes for the Child STEPs randomized
wards what matters. New York: Avery, 2019. 103. Viskovich S, Pakenham KI. Randomized con- effectiveness trial: a comparison of modular and
85. Hayes SC. Constructing a liberated and modern trolled trial of a web-based acceptance and standard treatment designs with usual care. J
mind: six pathways from pathology to euthymia. commitment therapy (ACT) program to pro- Consult Clin Psychol 2013;81:999-1009.

374 World Psychiatry 20:3 - October 2021

120. Eells TD. Handbook of psychotherapy case for- based approach to psychological diagnosis and 126. Jacob KS, Patel V. Classification of mental disor-
mulation. New York: Guilford, 2010. treatment: the conceptual and treatment utility ders: a global mental health perspective. Lancet
121. Fernandez KC, Fisher AJ, Chi C. Development of an extended evolutionary model. Clin Psychol 2014;383:1433-5.
and initial implementation of the Dynamic As- Rev 2020:82;101908. 127. Hayes SC, Nelson RO, Jarrett R. Treatment utility
sessment Treatment Algorithm (DATA). PLoS 124. Insel T, Cuthbert B, Garvey M et al. Research of assessment: a functional approach to evalu-
One 2017;12:e0178806. Domain Criteria (RDoC): toward a new classifi- ating the quality of assessment. Am Psychol
122. Bonow JT, Follette WC. “Idionomographic” as- cation framework for research on mental disor- 1987;42:963-74.
sessments: the future of clinical behavior ana- ders. Am J Psychiatry 2010;167:748-51.
lytic research and practice? Denver: Association 125. Olfson M, Marcus SC. National trends in out­ DOI:10.1002/wps.20884
for Behavior Analysis International, 2011. patient psychotherapy. Am J Psychiatry 2010;167:
123. Hayes SC, Hofmann SG, Ciarrochi J. A process- 1456-63.

World Psychiatry 20:3 - October 2021 375