Hayes and Hofmann¹ argue for the value of “third-wave” cognitive behavioral therapies (CBTs) – with which I heartily agree – and call for a renewed focus on targeting an expanded range of processes of change. They highlight five features of “third-wave” therapies: a) a focus on context and function; b) the view that new mod­els and meth­ods should build on other strands of CBT; c) a focus on broad and flexible repertoires; d) applying processes to the clinician; and e) expanding into more complex issues that historically were addressed by humanistic, existential and dynamic perspectives.

Variation is always to be desired and, if we have learned anything over the last century, it is that “one size does not fit all”. We have made some marvelous strides in the field (we have doubled the efficacy of treatments for depression since the 1970s), but we are only about halfway to where we want to be. Midway through the second year of my “internship” at the University of Pennsylvania, in 1976, I was called into the office of the associate director of the training program and told “Steve, we have a problem”. When I asked what the problem was, he told me that I was discharging my patients too fast. When I said that they were better, he told me that what I was observing was a “flight into health” and that I risked pushing my patients into psychotic decompensations if I insisted on treating their symptoms. We now know that any of several different types of psychotherapy are as efficacious as antidepressants for depression, and that both cognitive therapy (“second wave”) and perhaps behavior­al activation (“third wave”) have enduring effects that medications lack.

Nothing works for everyone, and the more different “arrows in our quiver”, the better for all. We now have tools at our disposal that can tell us what works best for whom, and the early indications are that some people will respond to one treatment who will not respond to another². Hayes and Hofmann criticize the application of treatment packages to diagnostic categories, and I appreciate their critique. That being said, two-thirds of the patients meeting criteria for major depressive disorder in the trials that I do also meet criteria for other Axis I disorders, and half meet criteria for at least one Axis II disorder. While I do attend to the content of my patients’ beliefs (more than their context) and often encourage them to use their own behaviors to test their accuracy, what I do and how I do it varies from one patient to the next. Most patients see themselves as either unlovable or incompetent, but precisely how that came to be and what tests they find compelling varies across patients. If Hayes and Hofmann can help lay that out, I am all ears.

I am a huge fan of D. Clark and his colleagues at Oxford and wrote a paper recently in which I speculated about how it is that they have been so successful in the approaches they have developed³. Clark essentially cured panic disorders, and a recent network meta-analysis found his approach to individual cognitive therapy to be the single most efficacious treatment for social anxiety⁴. He also found time to reshape the mental health care system in the UK to increase access to empirically supported treatments⁵. His partner A. Ehlers has a “kinder gentler” cognitive approach to the treatment of post-traumatic stress disorder that is as efficacious as prolonged exposure, with considerably less attrition. P. Salkovskis knows more about the treatment of obsessive-compulsive disorder than anyone else I am aware of and would be my “go to” person for a really tough patient that I did not fully understand. C. Fairburn generated the single most crushing defeat for another therapy in the literature when 20 weeks of his CBT for eating disorders was more than twice as efficacious as two years of dynamic psychotherapy⁶. D. Freeman is doing some very innovative work with virtual reality in the treatment of paranoid ideation in the schizophrenias⁷. As best I could surmise, the crux of what these colleagues all do is to talk with their patients to get a sense of the idiosyncratic beliefs shaping their problematic behaviors and of what kind of experiences would be required to produce change. The approach they seem to share is to move from open-ended conversations with their patients to identifying possible mechanisms that they then use to develop intervention strategies that they test first in analogue studies and then in clinical trials⁸. This process is anything but formulistic and it is incredibly successful.

If Hayes and Hoffman can improve on this record for even some, I am all for it and I would not bet against them. As the authors suggest, the “second wave” (cognitive) stood on the shoulders of the “first wave” (behavioral), and it seems right and fitting that the “third wave” should do the same. I wholly agree that we want to follow principles, not protocols, and that the processes that generate and maintain the problems our patients encounter will provide guidance along the way.

I have become enamored with an evolutionary perspective in recent years, and I understand from our conversations that this is true of the authors too. I have come to think of most high-prevalence low-heritability psychiatric “disorders” that revolve around negative affect, such as depression and anxiety, as adaptations that evolved to serve a function in our ancestral past⁹. I put the term “disorders” in quotes because these adaptations are neither diseases (there is nothing “broken in the brain”) nor “disorders”; rather, they coordinate an integrated but differentiated array of whole-body responses to various environmental challenges that increased the reproductive fitness of our ancestors. These evolved adaptations are at least as well treated with psychosocial interventions that facilitate the functions that they evolved to serve as they are with medications, and the former often have an enduring effect that medications simply lack. The low-prevalence high-heritability disorders like the schizophrenias or psychotic bipolar disorder likely are “true” diseases in the classic sense of the term and at this time are best treated with medications.

Not all that comes down to us from the past is necessarily wrong, but I do think that any “good idea” tends to be taken too far. When you have a hammer, everything becomes a nail. Variation, selection and retention are the essence of evolution. Mutations produce variation, some of which is selected­ if it outperforms its competition and, if it does, it is then retained in the genes. This process that differentiates and improves the species can do the same for treatment interventions. The authors are to be congratulated for thinking outside the box (introducing variation). If what they produce can outperform the competition, “third wave” processes will thrive and be retained.

Hayes 和 Hofmann ¹主张“第三波”认知行为疗法 (CBT) 的价值 — — 我衷心同意 — — 并呼吁重新关注针对扩大范围的变革过程。他们强调了“第三波”疗法的五个特点：a）注重背景和功能； b) 新模型和方法应建立在 CBT 其他方面的观点； c) 注重广泛且灵活的剧目； d) 将流程应用于临床医生； e) 扩展到历史上通过人文主义、存在主义和动态视角解决的更复杂的问题。

变化总是我们所希望的，如果说我们在上个世纪学到了什么的话，那就是“一刀切”。我们在这一领域取得了一些惊人的进步（自 20 世纪 70 年代以来，我们已经将抑郁症治疗的疗效提高了一倍），但我们距离我们想要达到的目标仅完成了大约一半。 1976 年，我在宾夕法尼亚大学“实习”的第二年中途，我被叫到培训项目副主任的办公室，并告诉我“史蒂夫，我们遇到了问题”。当我问问题出在哪里时，他告诉我，我让病人出院太快了。当我说他们好多了时，他告诉我，我所观察到的是“飞向健康”，如果我坚持治疗他们的症状，我就有可能将患者推向精神失代偿。我们现在知道，几种不同类型的心理治疗中的任何一种都与抗抑郁药一样有效治疗抑郁症，并且认知治疗（“第二波”）和行为激活（“第三波”）都具有药物所缺乏的持久效果。

没有什么对每个人都有效，“箭袋里的箭”越不同，对所有人都越好。我们现在拥有可以使用的工具，可以告诉我们什么对谁最有效，早期迹象表明，有些人会对一种治疗有反应，而对另一种治疗没有反应² 。海耶斯和霍夫曼批评治疗方案在诊断类别中的应用，我很欣赏他们的批评。话虽这么说，在我所做的试验中，符合重度抑郁症标准的患者中有三分之二也符合其他 I 轴疾病的标准，一半符合至少一种 Axis II 疾病的标准。虽然我确实关注患者信念的内容（不仅仅是他们的背景），并经常鼓励他们用自己的行为来测试他们的准确性，但我所做的事情以及如何做却因患者而异。大多数患者认为自己要么不可爱，要么无能，但这种情况到底是如何发生的，以及他们认为哪些测试引人注目，因患者而异。如果海耶斯和霍夫曼能够帮助阐明这一点，我会洗耳恭听。

我是 D. Clark 和他在牛津的同事的超级粉丝，最近写了一篇论文，其中我推测他们开发的方法为何如此成功³ 。克拉克基本上治愈了恐慌症，最近的一项网络荟萃分析发现，他的个体认知疗法是治疗社交焦虑的最有效的方法⁴ 。他还抽出时间重塑英国的精神卫生保健系统，以增加获得经验支持治疗的机会⁵ 。他的搭档 A. Ehlers 有一种“更友善、更温和”的认知方法来治疗创伤后应激障碍，这种方法与长期接触一样有效，而且损耗要少得多。 P.萨尔科夫斯基斯（P. Salkovskis）对强迫症治疗的了解比我认识的任何人都多，并且对于我不完全理解的非常棘手的患者来说，他将是我的“求助”人选。 C. Fairburn 在文献中对另一种疗法造成了最惨重的失败，当时他针对饮食失调进行的 20 周 CBT 的疗效是两年动态心理疗法的两倍多⁶ 。 D. Freeman 正在利用虚拟现实进行一些非常创新的工作，用于治疗精神分裂症的偏执观念⁷ 。据我推测，这些同事所做的工作的关键是与患者交谈，以了解塑造他们问题行为的特殊信念，以及需要什么样的经历才能产生改变。 他们似乎分享的方法是从与患者进行开放式对话转向确定可能的机制，然后使用这些机制来制定干预策略，并首先在模拟研究中进行测试，然后在临床试验中进行测试⁸ 。这个过程绝非公式化，而且非常成功。

如果海耶斯和霍夫曼甚至可以在某些方面提高这一记录，我会全力支持，并且我不会打赌他们。正如作者所言，“第二波”（认知）站在“第一波”（行为）的肩膀上，“第三波”也应该这样做，这似乎是正确且恰当的。我完全同意，我们要遵循原则，而不是协议，并且产生和维持患者遇到的问题的过程将提供指导。

近年来，我开始迷恋进化论的观点，从我们的谈话中我了解到，作者也是如此。我开始认为，大多数高患病率、低遗传力的精神“疾病”都与负面情绪有关，例如抑郁和焦虑，它们是为了在我们祖先的过去发挥作用而进化而来的适应性⁹ 。我将“障碍”一词放在引号中，因为这些适应既不是疾病（大脑中没有任何东西“损坏”），也不是“障碍”；它们是一种适应。相反，它们协调一系列综合但有区别的全身反应来应对各种环境挑战，从而提高了我们祖先的生殖适应性。这些进化的适应性至少可以通过心理社会干预得到很好的治疗，这些干预可以促进它们进化出的功能，就像药物一样，而且前者往往具有药物所缺乏的持久效果。低患病率的高遗传性疾病，如精神分裂症或精神病性双相情感障碍，可能是经典意义上的“真正的”疾病，此时最好采用药物治疗。

过去的一切并不一定都是错误的，但我确实认为任何“好主意”往往都被采取得太过分了。当你有了锤子，一切都变成了钉子。变异、选择和保留是进化的本质。突变会产生变异，其中一些变异如果胜过竞争就会被选择，如果确实如此，它就会保留在基因中。这一区分和改进物种的过程对于治疗干预也能起到同样的作用。作者们因跳出框框思考（引入变化）而受到祝贺。如果他们生产的产品能够超越竞争对手，“第三波”流程就会蓬勃发展并得以保留。