Hayes and Hofmann¹ discuss the neglect of processes of change in psychotherapy and the lessons we can learn from process research in the context of “third-wave” cog­nitive behavioral therapies (CBTs). They criticize the notion of psychiatric syndromes and argue that these newer therapies should be considered in the context of an idio­graphic approach to process-based functional analysis.

Although I do agree upon several of the arguments the authors put forward, there are a few issues on which my views are some­what different. As to their critic to the latent disease model of psychiatry, they do not discuss the progress which is now being made by the network approach. This approach to psychopathology posits that mental disorders can be conceptualized as causal systems of mutually reinforcing symptoms². The model has been used over the past decade to examine psychiatric comorbidity and developmental psychopathology, and is being applied to a variety of specific disorders, such as anxiety disorders, autism, depression, post-traumatic stress disorder, eating disorders, psychosis and psychopathy.

Hayes and Hofmann argue that in the 1980s the golden era of “protocols for syndromes” settled in, with an ignorance of the therapeutic processes involved in these CBT protocols. This observation may be partly correct, but it is important to note that the CBT movement has always emphasized the role of theory, and of basic research supporting this theory³. Nevertheless, the dominant paradigm has indeed been evidence-based treatment. Expert committees have been providing guidelines for evidence-based treatment of mental disorders, thus “certifying” a given treatment for a given population based on its proven efficacy for that specific mental disorder in randomized controlled trials (RCTs).

It should be acknowledged that this approach has led to a number of evidence-based CBT treatments for many mental dis­orders⁴. At the same time, about 30-40% of patients cannot be successfully treated with current CBT protocols, including “third-wave” CBTs, such as acceptance and commitment therapy (ACT), compassion-focused therapy, mindfulness-based cognitive therapy (MBCT), meta-cognitive therapy, and functional analytic psychotherapy. Although “third-wave” therapies are more experiential and “may lead to positive outcomes for trainees and practitioners”¹, there is no robust evidence that they are more effective than classic behavior therapies or “second wave” CBTs^{5, 6}.

One important way to investigate mechanisms of change is mediation. Several potential mediators have been proposed in the literature in relation to depression. Cognitive theory states that depression is caused and maintained by dysfunctional cognitions and maladaptive information processing strategies, and depression severity can be reduced by altering the function, content and structure of cognitions associated with negative affect, as is done in CBT. Changing the content of thoughts is seen as an unnecessary step in ACT, as it is assumed that distancing oneself from thoughts is a sufficient and more productive way to diminish the influence of thoughts on behavior. Distancing is achieved through the process of defusion or decentering.

In an RCT⁷, manualized CBT was compared with ACT, and patients in both conditions reported significant and large reductions of depressive symptoms aa well as improvement in quality of life up to 12 months after treatment. Interestingly, dysfunctional cognitions did not only mediate treatment effects of depressive symptoms in CBT, but also in ACT. On the other hand, decentering mediated not only treatment effects in ACT, but also in CBT. Thus, both treatments seem to work through changes in dysfunctional cognitions and decentering, even though the treatments differ substantially.

Another interesting issue for further re­search is the role of the therapeutic alliance in CBT and “third-wave” therapies. In an RCT⁸, the alliance-outcome association in CBT vs. MBCT was evaluated in diabetic patients with depressive symptoms. Because both CBT and MBCT therapists aim to form a therapeutic bond by adopting an open, empathic, accepting, and non-judging attitude towards patients, it was hypothesized that the therapeutic bond was going to predict the subsequent symptom change in both treatments. The results showed, however, that patients’ ratings of the therapeutic alliance predicted depressive symptom improvement in CBT, but not in MBCT. There is a clear need for further studies into the role of the therapeutic alliance in “third-wave” therapies.

Although the empirically supported treatment approach is currently still followed by a majority of CBT researchers and practitioners, a growing minority argues for the need to put greater emphasis on individual case formulation based on empirically tested theories instead of treatment protocols. Hayes and Hofmann suggest to study processes of change in therapy using idiographic analysis for nomothetic purposes and to treat the individual patient “by understanding the process-based complexity of his/her problem and applying tailored intervention strategies”¹. But, what is the evidence that individualized treatment based on functional analysis and case formulation is more effective than standard protocolized treatment?

Hayes and Hofmann cite two studies to support the notion that treatment modules to target person-specific maladaptive processes of change are more effective than glob­al protocols. In one of these studies⁹, an individualized approach was found to be more effective than standard treatment in children with behavioral problems. However, only about one half of children in the control condition actually engaged in behavioral health services. To test the study hypothesis, the individualized approach should be compared with an evidence-based treatment for behavioral problems.

Actually, there is no robust evidence for a superior effectiveness of treatment based on functional analysis compared with manualized evidence-based treatments². Although there are clear advantages associated with an individualized approach, if proven effective, there are also disadvantages. First, the success of the therapy will largely depend upon the therapist’s creativity. Moreover, an individualized treatment approach is certainly much more difficult to learn and practice than a manual-based, standardized, evidence-based intervention.

Hayes 和 Hofmann ¹讨论了心理治疗中对变化过程的忽视，以及我们可以从“第三波”认知行为疗法（CBT）背景下的过程研究中学到的教训。他们批评精神综合症的概念，并认为这些新疗法应该在基于过程的功能分析的具体方法的背景下考虑。

尽管我确实同意作者提出的一些论点，但在一些问题上我的观点有些不同。至于他们对精神病学潜在疾病模型的批评，他们没有讨论网络方法目前正在取得的进展。这种精神病理学方法认为，精神障碍可以被概念化为相互强化的症状的因果系统²。该模型在过去十年中已被用于检查精神共病和发展性精神病理学，并应用于各种特定疾病，例如焦虑症、自闭症、抑郁症、创伤后应激障碍、饮食失调、精神病和精神病。

Hayes 和 Hofmann 认为，20 世纪 80 年代“综合症方案”的黄金时代已经到来，但人们对这些 CBT 方案所涉及的治疗过程却一无所知。这一观察可能部分正确，但值得注意的是，CBT 运动始终强调理论和支持该理论的基础研究的作用³。尽管如此，主导范式确实是循证治疗。专家委员会一直在为精神障碍的循证治疗提供指南，从而根据随机对照试验（RCT）中已证明的对特定精神障碍的疗效来“证明”针对特定人群的特定治疗方法。

应该承认，这种方法已经催生了许多针对许多精神障碍的循证 CBT 治疗 4 。 与此同时，约30-40%的患者无法通过当前的CBT方案成功治疗，包括“第三波”CBT，如接受与承诺疗法（ACT）、同情聚焦疗法、基于正念的认知疗法（ MBCT）、元认知疗法和功能分析心理疗法。尽管“第三波”疗法更具体验性，并且“可能为受训者和从业者带来积极的结果” ¹，但没有强有力的证据表明它们比经典行为疗法或“第二波”CBT 更有效^{5, 6}。

研究变革机制的一种重要方法是调解。文献中已经提出了与抑郁症相关的几种潜在调节因素。认知理论指出，抑郁症是由功能失调的认知和适应不良的信息处理策略引起和维持的，并且可以通过改变与负面情绪相关的认知功能、内容和结构来减轻抑郁症的严重程度，就像 CBT 所做的那样。改变思想内容被视为 ACT 中不必要的步骤，因为人们认为远离思想是减少思想对行为影响的充分且更有效的方法。距离是通过解离或偏心过程实现的。

在一项 RCT ⁷中，手动 CBT 与 ACT 进行了比较，两种情况下的患者均报告治疗后 12 个月内抑郁症状显着且大幅减少，生活质量也得到改善。有趣的是，功能失调的认知不仅在 CBT 中介导抑郁症状的治疗效果，而且在 ACT 中也介导抑郁症状的治疗效果。另一方面，偏心不仅介导 ACT 中的治疗效果，而且还介导 CBT 中的治疗效果。因此，这两种治疗似乎都通过改变功能失调的认知和偏心来发挥作用，尽管治疗方法有很大不同。

进一步研究的另一个有趣问题是治疗联盟在 CBT 和“第三波”疗法中的作用。在一项随机对照试验⁸中，在患有抑郁症状的糖尿病患者中评估了 CBT 与 MBCT 的联合结果关联。由于 CBT 和 MBCT 治疗师的目标都是通过对患者采取开放、同理心、接受和非评判的态度来形成治疗纽带，因此假设治疗纽带将预测两种治疗中随后的症状变化。然而，结果显示，患者对治疗联盟的评分可以预测 CBT 中抑郁症状的改善，但不能预测 MBCT 中抑郁症状的改善。显然需要进一步研究治疗联盟在“第三波”疗法中的作用。

尽管目前大多数 CBT 研究人员和从业者仍然遵循经验支持的治疗方法，但越来越多的少数人认为需要更加重视基于经验检验的理论而不是治疗方案的个体病例制定。海耶斯和霍夫曼建议使用具体分析来研究治疗的变化过程，并“通过了解他/她的问题的基于过程的复杂性并应用量身定制的干预策略”来治疗个体患者¹。但是，有什么证据表明基于功能分析和病例制定的个体化治疗比标准方案治疗更有效呢？

海耶斯和霍夫曼引用了两项研究来支持这一观点，即针对特定个人适应不良的变化过程的治疗模块比全球方案更有效。其中一项研究⁹发现，对于有行为问题的儿童，个体化方法比标准治疗更有效。然而，只有大约一半的对照组儿童真正参与了行为健康服务。为了检验研究假设，应将个体化方法与行为问题的循证治疗进行比较。

事实上，没有强有力的证据表明基于功能分析的治疗与手动循证治疗相比具有更好的效果²。尽管个性化方法有明显的优点，但如果被证明有效，也有缺点。首先，治疗的成功很大程度上取决于治疗师的创造力。此外，个体化治疗方法肯定比基于手动、标准化、循证的干预措施更难学习和实践。