Arch

Hayes

Hofmann

Insel

Khoury

Klepac

Wolitzky-Taylor

World Psychiatry

English

Steven C. Hayes

Stefan G. Hofmann

Crossref

The third wave of cognitive behavioral therapy and the rise of process-based care

Hayes, Steven C.

Hofmann, Stefan G.

Boston University Institutional Repository (OpenBU)

ScholarWolf (University of Nevada, Reno)

WPAOFFICIAL JOURNAL OF THE WORLD PSYCHIATRIC ASSOCIATION (WPA)  Volume 16, Number 3 October 2017World PsychiatryISSN 1723-8617NEW IMPACT FACTOR: 26.561EDITORIALThe neurodevelopmental origins of  225schizophrenia in the penumbra of genomic medicine  D.R. WEINBERGERSPECIAL ARTICLESSchizophrenia and the neurodevelopmental 227continuum: evidence from genomicsM.J. OWEN, M.C. O’DONOVANStaging in bipolar disorder: from theoretical 236framework to clinical utilityM. BERK, R. POST, A. RATHEESH ET ALPERSPECTIVESThe third wave of cognitive behavioral therapy 245and the rise of process-based careS.C. HAYES, S.G. HOFMANNThe use of virtual reality in psychosis research 246and treatmentL. VALMAGGIAMental health Internet support groups: just a lot 247of talk or a valuable intervention?K.M. GRIFFITHSMental health interventions for people involved 249in disasters: what not to doN. GREENBERG, S. WESSELYFORUM – IMPROVING OUTCOMES OF FIRST-EPISODE PSYCHOSISImproving outcomes of first-episode  251psychosis: an overviewP. FUSAR-POLI, P.D. MCGORRY, J.M. KANECommentariesWhat are the key ingredients of optimal 266psychosocial treatment for persons recovering from a first episode of psychosis?K.T. MUESER, S.M. GLYNN, P.S. MEYER-KALOSTaking care of the carers: support for families 267of persons with early psychosis C. CORCORANTaking a Bleulerian perspective: a role for negative 268symptoms in the staging model?L. WUNDERINKEarly intervention in psychosis: p-values, policy, 270and politicsR. ROSENHECKAn international response to improving outcomes 271for first-episode psychosis is warranted, but more needs to be done to make it happenS. CHATTERJEEEarly intervention services are effective and 272must be defendedM. NORDENTOFT, N. ALBERTAdvances and challenges in early intervention 274in psychosisA. MALLA, J. SHAH, S. LALMoving interventions from after to before diagnosis 275I.E. SOMMER, C. ARANGOEarly intervention in psychosis: much done, 276much more to doS. SINGHRESEARCH REPORTSComparing three-year extension of early 278intervention service to regular care following two years of early intervention service in first-episode psychosis: a randomized single blind clinical trialA. MALLA, R. JOOBER, S. IYER ET ALThe efficacy of smartphone-based mental health 287interventions for depressive symptoms: a meta-analysis of randomized controlled trialsJ. FIRTH, J. TOROUS, J. NICHOLAS ET ALEstimating treatment coverage for people with 299substance use disorders: an analysis of data from the World Mental Health SurveysL. DEGENHARDT, M. GLANTZ, S. EVANS-LACKO ET ALSedentary behavior and physical activity levels  308in people with schizophrenia, bipolar disorder and major depressive disorder: a globalsystematic review and meta-analysisD. VANCAMPFORT, J. FIRTH, F.B. SCHUCH ET ALINSIGHTSScreening for depression: the global mental 316health contextC.F. REYNOLDS 3RD, V. PATELAntidepressants and suicide risk in depression 317P. COURTET, J. LÓPEZ-CASTROMANThe clinical relevance of qualitatively distinct 318subtypes of depressionL.V. KESSING, J.D. BUKHWho are excellent lithium responders and why 319do they matter?M. ALDALETTERS TO THE EDITOR 321WPA NEWS 329WORLDPSYCHIATRYVol. 16, No. 3, pp. 225-332OCTOBER2017WPS-C1SP  9/13/17  1:28 PM  Page 1The third wave of cognitive behavioral therapy and the rise of process-based careThe term cognitive behavioral therapy (CBT) identifies afamily of interventions that are widely recognized as the set ofpsychological treatments with the most extensive empiricalsupport1. CBT is not monolithic, however, and it has beenthrough several distinct eras, generations, or waves. The firstgeneration of this tradition was behavior therapy: the applica-tion of learning principles to well-evaluated methods designedto change overt behavior. By the late 1970s, behavior therapyhad moved into the era of classic CBT: a new generation ofmethods and concepts focused on the role of maladaptivethinking patterns in emotion and behavior, and the use ofmethods to detect and change those patterns.The arrival of a “third wave” of CBT was declared 13 yearsago2. The claim was that a change was occurring in orientingassumptions within CBT, and that a set of new behavioral andcognitive approaches were emerging based on contextual con-cepts focused more on the persons’ relationship to thoughtand emotion than on their content. Third wave methodsemphasized such issues as mindfulness, emotions, acceptance,the relationship, values, goals, and meta-cognition. New modelsand intervention approaches included acceptance and commit-ment therapy, dialectical behavior therapy, mindfulness-basedcognitive therapy, functional analytic psychotherapy, meta-cognitive therapy, and several others.The idea that a “third wave” of CBT had arrived led to sig-nificant controversy3. The metaphor of a “wave” suggested tosome that previous generations of work would be washedaway, but that was not the intent and that was not the result.Waves hitting a shore assimilate and include previous waves –but they leave behind a changed shore. It seems to us that weare now in a position to begin to evaluate what will be leftbehind in a more permanent way from third wave CBT.There is no doubt that several concepts and methods thathave been central to third wave interventions (mindfulnessmethods; acceptance-based procedures; decentering; cogni-tive defusion; values; psychological flexibility processes) arenow permanently part of the CBT tradition and indeed ofevidence-based therapy more generally, in large part becauseevidence suggests that they are helpful4. These newer conceptsand methods now largely co-exist side by side with previouslyestablished ones, with the dialectic between them serving as auseful spur to theoretical and technological investigation. Insome cases, we now know that traditional CBT methods workin part by changing processes that became central after thearrival of third wave methods5. Third wave methods have beenadded to packages that include traditional behavioral and cog-nitive methods, resulting in useful approaches6. Research hasbegun to identify moderators indicating when older and newermethods work best with different populations7, suggestingthat evidence-based practitioners can serve their clients byknowing methods from all of the CBT generations.While new concepts and methods are important, in ouropinion, there is a more profound set of changes that has beenintroduced by the third wave. A subtle but important change isthat there is now greater recognition of the central importanceof philosophical assumptions to methods of intervention andtheir analysis. Science requires pre-analytic assumptions aboutthe nature of data, truth, and the questions of importance, andsome of the differences between the waves and generations ofCBT work were philosophical, not empirical. Recognizing this,the Inter-Organizational Task Force on Cognitive and Behav-ioral Psychology Doctoral Education8 recently concluded thatall CBT training should place more emphasis on philosophy ofscience training, in the hope of increasing the coherence andprogressivity of research programs.An examination of assumptions leads naturally to a concernfor theories, models, and processes. The third wave has beenfar less focused on protocols for syndromes, and more focusedon evidence-based processes linked to evidence-based proce-dures8,9. Increased emphasis on processes of change and theirbiobehavioral impact has meanwhile been strengthened byResearch Domain Criteria10 and transdiagnostic models, amongother trends. A notable result is that there is now much morefocus on moderators and mediators of change, and the construc-tion of intervention models that emphasize the role of changeabletransdiagnostic processes (i.e., functionally important pathwaysof change that cut across various diagnostic categories).In part because of its greater process focus, modern CBTand evidence-based therapy is more open to the investigationof a wider range of approaches from humanistic, existential,analytic, and spiritual traditions. This promises over time toreduce the dominance within intervention science of walledoff schools of thought, or trademarked intervention protocols,and to bring different wings of the field together in an evidence-based search for coherent and powerful sets of change processes.As a purely syndromal focus weakens and a process focusstrengthens, human psychological prosperity and the thrivingof whole persons, not merely psychopathology, is also becom-ing more central. Behavioral and mental health is ultimatelyabout health, not solely the absence of disorders.This set of changes is accelerating a transition in evidence-based care toward a process-based field that seeks to integratethe full range of psychosocial and contextual biological pro-cesses. Such a field is so broad that it stretches the very termCBT almost to a breaking point and we would not be surprisedif that term soon wanes in importance.Researchers and practitioners alike seem ready for a turntoward process-based therapy (PBT), in which processes, pro-cedures and their linkage are evidence-based, and are used toalleviate the problems and promote the prosperity of people.Similar to the trend toward personalized and precision medicine,focusing on changeable processes that can make a difference inWorld Psychiatry 16:3 - October 2017 245PERSPECTIVESthe behavioral and mental health of individuals provides a wayfor evidence-based care and person-centered care to mergeunder a single umbrella of process-based care. Orienting thefield in that direction may ultimately be the most important“changed shore” produced by the third wave of CBT.Steven C. Hayes1, Stefan G. Hofmann21Department of Psychology, University of Nevada, Reno, NV, USA; 2Department ofPsychological and Brain Sciences, Boston University, Boston, MA, USA1. Hofmann SG, Asnaani A, Vonk IJ et al. Cogn Ther Res 2012;36:427-40.2. Hayes SC. Behav Ther 2004;35:639-65.3. Hofmann SG, Asmundson GJ. Clin Psychol Rev 2008;28:1-16.4. Khoury B, Lecomte T, Fortin G et al. Clin Psychol Rev 2013;33:763-71.5. Arch JJ, Wolitzky-Taylor KB, Eifert GH et al. Behav Res Ther 2012;50:469-78.6. Arch JJ, Eifert GH, Davies C et al. J Consult Clin Psychol 2012;80:750-65.7. Wolitzky-Taylor KB, Arch JJ, Rosenfield D et al. J Consult Clin Psychol2012;80:786-99.8. Klepac RK, Ronan GF, Andrasik F et al. Behav Ther 2012;43:687-97.9. Hayes SC, Hofmann SG (eds). Process-based CBT: the science and coreclinical competencies of cognitive behavioral therapy. Oakland: NewHarbinger, 2017.10. Insel T, Cuthbert B, Carvey M et al. Am J Psychiatry 2010;167:748-51.DOI:10.1002/wps.20442The use of virtual reality in psychosis research and treatmentRecent years have witnessed a renewed interest and an in-crease in the popularity of virtual reality, the aim of which is togenerate a virtual world that feels immersive and realistic. Theuser wears a head mounted display, and computer generatedimages and sounds are synchronized with his/her movements.The potential of virtual reality for mental health research,assessment and treatment is that it enables researchers andclinicians to bring real-time life experiences into a lab environ-ment. In standard practice, i.e. not in a virtual reality environ-ment, the assessment of clinically relevant phenomena – suchas neurocognitive processes, emotional reactions, physiologi-cal activation or behavioural responses – involves standardizedquestionnaires, semi-structured interviews about symptoms,doing computer tasks, watching videos or images, or role play-ing a situation while the physiological response is measured.Although the reliability and validity of these methods havebeen tested extensively, they lack ecological validity and donot represent the complexity of real life experiences1.The innovative potential of virtual reality is that it allows tomeasure real-time cognitive, emotional, physiological andbehavioural responses to a variety of “real-life” situations,while enabling experimental control.Till recently, the high cost of virtual reality equipment andsoftware as well as cyber-sickness, a side effect associated withthe older head mounted displays, have represented a majorbarrier to the implementation of virtual reality in standardpractice. As head mounted displays have become populardevices for entertainment and gaming, they are increasinglyaffordable, so that implementation of virtual reality in dailyclinical practice has come within reach.Enthusiasm is growing among clinicians and researchersaround the world about the potential that virtual reality offersto improve the assessment and treatment of mental and physicalhealth problems. Fortunately, this technique has been aroundfor over half a century and has been used in psychology researchfor well over 25 years2. A significant body of research has alsoexplored its use for the assessment and treatment of differentmental health problems, ranging from phobias, to eating disor-ders, autism and post-traumatic stress disorder3.A substantial number of studies have been conducted toestablish the safety of using virtual reality with people experi-encing psychosis and to elucidate the psychological mecha-nisms underlining the onset and maintenance of psychoticsymptoms4. In this type of studies, participants enter a virtualenvironment, like public transport or a cafe, populated by ava-tars who show behaviours which can be interpreted as ambig-uous, like for example looking at the participant and lookingaway. The occurrence of paranoid ideation or hallucinationstriggered during the virtual reality experience is then assessed.The use of virtual reality for the clinical assessment andtreatment of psychosis is still in its infancy, but the first clinicaltrials have been published or are ongoing. In these studiesparticipants either practice new social skills5, or are encour-aged to drop their safety behaviours and explore new ways of ap-proaching social situations6,7 or challenge the omnipotence ofthe voices they hear8. The initial results indicate that virtualreality assisted therapy can be a powerful tool to help peoplebreak the cycle of avoidance involved in the maintenance ofsymptoms and develop new skills and strategies to cope withthem. They also show that improvements are maintained atfollow-up.Although the coming years are exciting times for the devel-opment and implementation of virtual reality for psychosis,our enthusiasm should not prevent us from considering safetyand ethical concerns associated with this technique. Moreover,it is essential to emphasize that all research to date has evaluatedthe use of virtual reality as an adjunct to standard procedureswith a therapist guide and not as a stand-alone interventionwhich patients can download and follow on their own.Rigorous research is needed to confirm the initial positivefindings regarding the use of virtual reality assisted assessmentand therapy. To date most research in psychosis has focusedon paranoia and hallucinations, and there is an urgent need toexplore the use of virtual reality for negative symptoms. Futurestudies should integrate virtual reality with physiological mea-sures (e.g., galvanic skin response, cortisol levels, heart rate) tobetter understand the mechanisms that trigger and maintainpsychotic symptoms. Research endeavours should also inves-246 World Psychiatry 16:3 - October 2017

The third wave of cognitive  behavioral therapy and the rise of process-based care

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The third wave of cognitive behavioral therapy and the rise of process-based care

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