Hayes and Hofmann¹ describe how the context around cognitive behavioral therapy (CBT), a context that has supported significant success for many years, may now be stifling progress¹. They say that it is now time for a new strategic approach. In their words, a focus on syndromes, diagnostic categories, and the development of treatment protocols based on studies of group data, has dominated the field of mental health, perhaps for too long. New developments in CBT provide the chance to refocus on the unique problems that individual people face, and on custom-delivered methods targeting empirically-based processes of change, rather than packages of methods prescribed by a protocol. This evolution of CBT toward more person-specific and process-focused delivery presents an opportunity to transform mental health care. Clearly this ought to apply to physical health care as well.

While there is no quibbling with the authors’ reminder that depression is one of the world’s leading causes of disability, it is also worth pointing out that the top ten contributors to the global burden of disease in adults include low back pain, headache disorders, ischemic heart disease, and stroke². In fact, each of these conditions actually surpasses even the substantial disease burden of depression in people aged 25 to 49, and, excluding headache, in people aged 50 to 74.

What makes this relevant is that each of these conditions involves a substantial role for modifiable cognitive and behavior­al processes. In each case, risk factors that lead to the development and maintenance of these conditions, and the processes that translate the experience of these conditions into impacts on daily functioning, and years lived with disability, can be substantially modified with forms of CBT. These include newer, “third wave”, forms^{e.g., 3, 4}.

The point is that, even with the great need for improving mental health worldwide, we should not lose sight of the need for cutting across the assumed border between mental and physical health, to consider the opportunity for world health as a whole. This boundary is called “assumed” because so-called mental and physical health conditions are highly comorbid, certainly share many risk factors, worsen under many of the same influences, and improve with application of many of the same kinds of treatment methods. Individual behavior is an extremely powerful common pathway toward general health and well-being, as well as an outcome or indicator of these, more so than we often think.

In some ways, the contexts of physical health provide easier access for person-specific and process-focused approaches. The door is already open to a degree. When people have chronic pain, headache, heart disease, cancer or diabetes, as examples, they already have a diagnosis and clearly their focus and the focus of clinicians, at least in part, is on addressing the impacts of these conditions. That being the case, there can be less an urgency around assigning another diagnosis in the realm of mental health. Also, a focus on multiple outcomes, on healthy behavior, on functioning well and well-being, and not just on symptom reduction, is already a relatively ordinary focus in the domain called clinical health psychology or behavioral medicine, essentially the domain where CBT operates in physical health. This appears particularly true in the context of chronic diseases.

Seizing the opportunity for enhancing physical health through the application of new CBT methods is not without potential impediments. For example, in chronic pain management, particularly in specialty centers, CBTs are traditionally delivered in groups. Also, in most health care research, studies are based on group data, normally collected at relatively infrequent intervals, before treatment, immediately after treatment, and at a later follow-up. This focus on groups clearly presents significant difficulties, if the aim is highly individualized treatment. Group delivery and a focus on group means are not likely to yield the knowledge needed, if the need in knowledge is how to customize the delivery of treatment components and to selectively target only relevant process of change for each person⁵. The infrequent assessment of outcomes, and presumed mediators of outcome, if included, is unlikely to detect complex, multivariate, bidirectional, and highly individual processes of change⁶.

In the future, we will need to more frequently employ single case experimental designs with intensive longitudinal data gathering. As well as needing to build a library of theoretically derived and empirically-based therapeutic processes of change, we will also need to harness new technologies for data gathering and analysis. These data will most likely be collected by hand-held “smart” devices that include a new generation of outcome and process measures which are brief, individually-relevant, and sensitive to change. Analyses of these data will then allow analyses of potential mechanisms of change in highly individual ways, and meta-analyses of these case data will allow the development of new general principles, and a science of truly personalized therapy will finally emerge⁶.

Another possible impediment to change in CBT for physical health resides in the predominantly interdisciplinary context of much of this work. When working in interdisciplinary teams, it seems necessary that all members know what the others are doing and why. With the appearance of new approaches, some members of teams may express frustration, such as to say that now we must train colleagues all over again. While this frustration might be understandable, change will come, approaches will evolve. And this is not a break from past learning, but an extension. Moreover, the alternative – staying the same – is both undesirable and ultimately impossible.

Important steps are already being made. Implementation of “third wave” therapies well-suited to process-based delivery is expanding rapidly in physical health contexts, as demonstrated in published ran­domized controlled trials dealing with bowel disease, cancer, chronic pain, dialysis, diabetes, epilepsy, exercise, headache, HIV, multiple sclerosis, sleep, smoking, tinnitus, and weight loss⁷. A focus in research on predictors and mediators of outcome is becoming common^{e.g., 8}. And in the wider field of CBT there are now an increasing number of studies that employ single case approaches. These studies are now able to analyze processes of therapeutic change, using methods for gathering data daily, including ecological momentary assessment. They can also apply methods for analyzing process and outcome data that allow individualized targeting of key functional processes of change, including factor analysis and network analyses of ­individual data⁹.

While there is progress, at the same time there is much to do so that these developments will continue. We need to produce new knowledge, new applications of current technology and new technology, and we need to educate and train. Perhaps in small steps, process-based therapy designed around the specific needs of individual people, for both mental and physical health, is becoming a reality.

Hayes 和 Hofmann ¹描述了认知行为疗法 (CBT) 的背景（多年来支持显着成功的背景）现在可能如何阻碍进展¹。他们表示，现在是采取新战略方针的时候了。用他们的话说，对综合症、诊断类别以及基于群体数据研究的治疗方案的关注已经主导了心理健康领域，也许已经持续太久了。CBT 的新发展提供了重新关注个人面临的独特问题的机会，以及针对基于经验的变革过程的定制方法，而不是协议规定的方法包。CBT 向更加针对个人和以流程为中心的交付方式的演变为改变心理健康护理提供了机会。显然，这也应该适用于身体保健。

虽然作者毫无疑问地提醒人们，抑郁症是世界上导致残疾的主要原因之一，但也值得指出的是，造成全球成人疾病负担的十大因素包括腰痛、头痛、缺血性心脏病和中风²。事实上，这些病症实际上甚至超过了 25 至 49 岁人群中抑郁症的重大疾病负担，并且（排除头痛）50 至 74 岁人群中的抑郁症负担。

之所以如此重要，是因为这些条件中的每一个都涉及可改变的认知和行为过程的重要作用。在每种情况下，导致这些状况发生和维持的风险因素，以及将这些状况的经历转化为对日常功能和残疾寿命的影响的过程，都可以通过认知行为疗法的形式得到实质性改变。其中包括较新的“第三波”形式，^{例如 3、4}。

关键是，即使全世界迫切需要改善心理健康，我们也不应该忽视跨越心理健康和身体健康之间假定界限的必要性，并考虑整个世界健康的机会。这个界限被称为“假设的”，因为所谓的精神和身体健康状况是高度共病的，当然有许多共同的危险因素，在许多相同的影响下恶化，并随着许多相同类型的治疗方法的应用而改善。个人行为是通向总体健康和福祉的极其强大的共同途径，也是这些结果或指标，比我们通常想象的更重要。

在某些方面，身体健康的背景为针对特定个人和以过程为中心的方法提供了更容易的途径。大门已经打开到一定程度。例如，当人们患有慢性疼痛、头痛、心脏病、癌症或糖尿病时，他们已经有了诊断，并且显然他们的重点和临床医生的重点，至少部分是在解决这些疾病的影响上。既然如此，在心理健康领域进行另一种诊断就不那么紧迫了。此外，在临床健康心理学或行为医学领域（本质上是 CBT 运作的领域），关注多种结果、健康行为、功能良好和福祉，而不仅仅是减少症状，已经是一个相对常见的关注点。在身体健康方面。在慢性病的背景下尤其如此。

抓住机会通过应用新的认知行为治疗方法来增强身体健康并非没有潜在的障碍。例如，在慢性疼痛管理中，特别是在专科中心，CBT 传统上是分组进行的。此外，在大多数医疗保健研究中，研究都是基于群体数据，这些数据通常以相对不频繁的间隔、治疗前、治疗后立即和随后的随访收集。如果目标是高度个体化的治疗，这种对群体的关注显然会带来很大的困难。如果知识需求是如何定制治疗组件的交付并有选择地仅针对每个人的相关变革过程，则小组交付和对小组手段的关注不太可能产生所需的知识⁵。对结果和假定的结果中介因素（如果包括在内）的不频繁评估不太可能检测到复杂的、多变量的、双向的和高度个体化的变化过程⁶。

未来，我们将需要更频繁地采用单案例实验设计和密集的纵向数据收集。除了需要建立一个基于理论和基于经验的治疗过程的库之外，我们还需要利用新技术进行数据收集和分析。这些数据很可能通过手持式“智能”设备收集，其中包括新一代的结果和过程测量，这些测量简短、与个人相关且对变化敏感。对这些数据的分析将允许以高度个性化的方式分析潜在的变化机制，而对这些病例数据的荟萃分析将允许制定新的一般原则，真正的个性化治疗科学将最终出现⁶。

改变 CBT 对身体健康的另一个可能的障碍在于这项工作的大部分内容主要是跨学科背景。在跨学科团队中工作时，所有成员似乎有必要知道其他人在做什么以及为什么这样做。随着新方法的出现，一些团队成员可能会表示沮丧，比如说现在我们必须重新培训同事。虽然这种挫败感可能是可以理解的，但变化将会到来，方法将会演变。而且这并不是对过去学习的突破，而是一种延伸。此外，另一种选择——保持不变——既是不可取的，也是最终不可能的。

重要的步骤已经在采取中。正如已发表的涉及肠道疾病、癌症、慢性疼痛、透析、糖尿病、癫痫、运动、头痛、 HIV、多发性硬化症、睡眠、吸烟、耳鸣和体重减轻⁷。对结果的预测因素和中介因素的研究越来越普遍^{，例如 8}。在更广泛的 CBT 领域，现在越来越多的研究采用单案例方法。这些研究现在能够使用每天收集数据的方法（包括生态瞬时评估）来分析治疗变化的过程。他们还可以应用分析过程和结果数据的方法，以实现对关键功能变革过程的个性化定位，包括个体数据的因素分析和网络分析⁹。

虽然取得了进展，但同时还有很多工作要做，以便这些发展能够继续下去。我们需要产生新知识、现有技术和新技术的新应用，我们需要教育和培训。或许，围绕个人心理和身体健康的特定需求而设计的基于过程的治疗正在逐步成为现实。