Hayes and Hofmann¹ provide a sweeping history of behavioral approaches to clinical practice, from applied behavior analysis, through cognitive behaviorism, to contemporary “third-wave” approaches. Reviewing their history from my vantage points – as a clinician, a motivational researcher, and a psychological theorist – engenders different reactions, two quite positive and one more skeptical.

As a clinician, and former trainer of therapists, I laud the more “process-oriented” point of view represented by the “third wave”, which conveys respect for individuals’ perspectives and values, and greater flexibility regarding the directions of treatment. Both applied behavioral analyses and cognitive behavioral approaches (the first “two waves” of behaviorism described by the authors) have traditionally embraced an outcome focus to treatment – applying techniques and interventions to bring about pre-defined targets of behavioral change and involving therapist-directed activities such as teaching, training, shaping and rewarding.

Such outcome-focused approaches often either assume or select for motivation or “readiness” for change, such that patients can “fail the therapy”². In contrast, process-focused approaches conceptualize both motivation and resistance as part of the change process, and are centrally concerned with the client’s experience and volition with respect to change. Process-focused therapists emphasize activities of listening, reflecting, empathizing and facilitating. These are empowering, autonomy-supportive and relational activities.

Another important, and laudable, feature in Hayes and Hofmann's depiction of the “third wave” relative to prior behaviorisms is a focus not merely on behavior change, but rather on the “development and use of inner resources” for ongoing adaptive self-regulation. Highlighted is the person's relationship with events, cognitions and emotions, and developing a sense of awareness, value, and volition in reacting to them. A focus on facilitating such self-regulatory resources highlights new assumptions concerning internalized capacities and mechanisms of agency that prior waves of behavioral theory did not acknowledge, but which (in this clinician's view) are essential to maintained change and the enhancement of adaptive functioning amidst the ever changing environments people encounter.

As a researcher, I am particularly struck by the convergence of these “third-wave” ideas – particularly those embedded within acceptance and commitment therapy (ACT) and mindfulness-based cognitive therapy – with research accomplished within self-determination theory (SDT)³. SDT studies have, for example, shown that more self-endorsed or autonomous motivations are reliably associated with greater engagement, behavioral persistence, as well as more positive experience⁴.

Clinical and applied research within SDT has also shown that a facilitating environment of acceptance and autonomy support enhances treatment motivation, engagement and success⁵, offering a promising interface for applying SDT’s research methods and concepts to ACT interventions in particular. Such theoretical iteration has been illustrated by work applying SDT to motivational interviewing⁶. Moreover, SDT models of change also suggest that mindful awareness facilitates greater autonomy in functioning, and in turn greater wellness. Indeed, a recent meta-analysis supports SDT's nuanced assumption of graded associations between mindfulness and more internalized and autonomous forms of motivation⁷, suggesting that awareness supplies a foundation for improved self-regulation.

In parallel, we see the ACT concept of “psychological flexibility” as entailing both mindful awareness and autonomy, constructs that have been well researched within the SDT tradition. Similarly, ACT appears to converge with SDT in advancing integrative forms of emotion regulation, in which persons approach and understand the meaning of emotional reactions, rather than focusing only on down-regulating or reframing negative experience⁸.

However positive my reactions as a cli­nician and researcher, I am a bit more skeptical regarding Hayes and Hofmann’s claims concerning the philosophical coherence or conceptual continuity of the third wave's theoretical constructs with prior behaviorisms, as if they represent a logical next step rather than a leap to a new foundation. Finding a way from Skinnerian positivism to ther­apies cultivating awareness, choice, and inner resources recalls an old joke involving getting directions from a rural farmer who states: “You can't get there from here”.

Classical behavioral theorists actively eschewed and often disparaged concepts such as awareness, volition and autonomy. And, although cognitive behavioral theorists accepted the reality of inner mediators between environments and behavioral outputs, their focus remained on leveraging these mediators toward behavior change, retaining an outcome focus². For example, Bandura explicitly dismissed concepts such as autonomy and basic psychological needs as inconsistent with his views⁹.

Hayes and Hofmann do establish some forms of continuity in that, like applied behavior analysis and cognitive behavioral theories, the new wave remains: a) evidence based; b) highly focused on contexts; and c) inconsistent with a medical model. But none of these general attributes is unique to behaviorisms and, more importantly, none establishes a deep theoretical or philosophical coherence of new-wave constructs with these old meta-theoretical foundations. This is not to say that connections cannot be established, but the question is whether these ideas and practices really fit well within such a procrustean bed. The core concepts underlying new-wave therapies involve authentically engaging clients, understanding their perspectives, and helping them build or access inner resources and capacities for reflective, value-based choices, concepts and practices that cannot be parsimoniously derived from earlier behaviorist worldviews.

Although doubtful of the congruence of many “third-wave” concepts with classical or cognitive behavioral theories, I am optimistic that the processes and models of the “third wave” can be both richly theoretically described and fruitfully studied within organismic perspectives such as SDT. Because the process-oriented issues of mindful awareness⁷, integrative emotion regulation⁸, autonomous treatment motivation⁵, basic psychological needs³ and other constructs relevant to new-wave behavioral interventions already have a coherent place within the system of concepts specified in SDT, research using this theoretical framework as either a primary or supplementary guide for research may help illuminate “active ingredients” in “third-wave” techniques.

Perhaps as importantly, the organismic meta-theory underlying SDT brings with it a person-centered sensibility and philosophy that is in itself important in effectively implementing new-wave clinical practices or, for that matter, any truly process-oriented approach. Process-oriented therapy approaches are not merely sets of techniques, but also entail an orientation toward perspective-taking, facilitation, and respect for autonomy. Part of the role of theory is to guide clinicians in developing, refining and implementing such orientations in their relationships with clients. The psychological principles and values forwarded within SDT seem, in this regard, well-matched with many of the “third-wave” sensibilities and values expressed by Hayes and Hofmann, and are integrated into a conceptual framework directly relevant to the innovations of this new movement.

Since the days of classical behaviorism, empirical models of human motivation have seen a “Copernican turn” – a movement away from models of people as pawns to external contingencies, toward a focus on the development and support of people’s inner capacities for acting. From this view, it is nice to see this turn within behaviorism away from assumptions that Hayes and Hofmann describe as “too narrow”, and toward a more person-centered point of view. Given SDT's past clashes with ­behaviorists, this openness of the “third wave” to a truly process-oriented perspective affords fresh opportunities for exchanging methods, find­ings and practices, and ultimately a more convergent clinical science.

Hayes 和 Hofmann ¹提供了临床实践行为方法的全面历史，从应用行为分析到认知行为主义，再到当代“第三波”方法。从我的角度——作为一名临床医生、一名动机研究者和一名心理学理论家——回顾他们的历史，会产生不同的反应，两种是非常积极的，一种是持怀疑态度的。

作为一名临床医生和前治疗师培训师，我赞赏“第三次浪潮”所代表的更加“以过程为导向”的观点，它表达了对个人观点和价值观的尊重，以及治疗方向上更大的灵活性。应用行为分析和认知行为方法（作者描述的行为主义的第一“两波”）传统上都接受以结果为重点的治疗——应用技术和干预措施来实现行为改变的预定目标，并涉及治疗师的指导教学、培训、塑造和奖励等活动。

这种以结果为中心的方法通常会假设或选择动机或“准备好”改变，从而导致患者“治疗失败” ² 。相比之下，以过程为中心的方法将动机和阻力概念化为变革过程的一部分，并集中关注客户对变革的体验和意愿。以过程为中心的治疗师强调倾听、反思、共情和促进的活动。这些是赋权、支持自主和关系活动。

相对于先前的行为主义，海耶斯和霍夫曼对“第三次浪潮”的描述的另一个重要且值得称赞的特征是，不仅关注行为改变，而且关注持续适应性自我调节的“内部资源的开发和使用”。强调的是人与事件、认知和情感的关系，以及在对这些事件做出反应时形成意识、价值和意志。对促进此类自我监管资源的关注凸显了有关内化能力和代理机制的新假设，先前的行为理论浪潮并未承认这些假设，但（在这位临床医生看来）这对于维持变革和增强适应性功能至关重要。人们遇到的环境不断变化。

作为一名研究人员，我对这些“第三波”思想的融合感到特别震惊——尤其是那些嵌入接受与承诺疗法（ACT）和基于正念的认知疗法中的思想——与在自我决定理论（SDT）中完成的研究³ 。例如，SDT 研究表明，更多的自我认可或自主动机与更大的参与度、行为持久性以及更积极的体验可靠​​相关⁴ 。

SDT 的临床和应用研究还表明，接受和自主支持的便利环境可以增强治疗动机、参与度和成功⁵ ，为将 SDT 的研究方法和概念应用于 ACT 干预措施提供了一个有前途的界面。将 SDT 应用于动机性访谈⁶的工作已经说明了这种理论迭代。此外，SDT 变革模型还表明，正念意识有助于提高功能自主性，进而提高健康水平。事实上，最近的一项荟萃​​分析支持 SDT 关于正念与更加内化和自主的动机形式之间的分级关联的微妙假设⁷ ，这表明意识为改善自我调节奠定了基础。

与此同时，我们认为 ACT 的“心理灵活性”概念包含正念意识和自主性，这些概念在 SDT 传统中已得到充分研究。同样，ACT 似乎与 SDT 共同推进了情绪调节的综合形式，即人们接近并理解情绪反应的含义，而不是仅仅关注下调或重构负面体验⁸ 。

无论我作为一名临床医生和研究人员的反应多么积极，我对海耶斯和霍夫曼关于第三次浪潮理论结构与先前行为主义的哲学一致性或概念连续性的主张持怀疑态度，就好像它们代表了逻辑上的下一步而不是飞跃到一个新的基础。寻找从斯金纳实证主义到培养意识、选择和内在资源的疗法的方法，让人想起一个古老的笑话，涉及从一个农村农民那里得到指示，他说：“你不能从这里到达那里”。

古典行为理论家积极回避并经常贬低意识、意志和自主等概念。而且，尽管认知行为理论家接受了环境和行为输出之间存在内在中介因素的现实，但他们的重点仍然是利用这些中介因素来改变行为，保留结果焦点² 。例如，班杜拉明确驳斥了自主性和基本心理需求等概念，认为这些概念与他的观点不一致⁹ 。

海耶斯和霍夫曼确实建立了某种形式的连续性，就像应用行为分析和认知行为理论一样，新浪潮仍然是：a）基于证据； b) 高度关注环境； c) 与医学模型不一致。但这些一般属性都不是行为主义所独有的，更重要的是，没有一个属性能够在新浪潮结构与这些旧的元理论基础之间建立深刻的理论或哲学一致性。这并不是说不能建立联系，但问题是这些想法和实践是否真的适合这样一个普罗克拉斯特斯的床。新浪潮疗法的核心概念涉及真正吸引客户，理解他们的观点，帮助他们建立或获取内在资源和能力，以进行反思性的、基于价值的选择、概念和实践，而这些是不能从早期的行为主义世界观中简单推导出来的。

尽管对许多“第三波”概念与经典或认知行为理论的一致性表示怀疑，但我乐观地认为，“第三波”的过程和模型可以在 SDT 等有机视角下得到丰富的理论描述和富有成效的研究。由于正念意识⁷ 、综合情绪调节⁸ 、自主治疗动机⁵ 、基本心理需求³以及与新浪潮行为干预相关的其他结构等面向过程的问题已经在 SDT 规定的概念体系中占有一席之地，研究使用这一理论框架作为研究的主要或补充指南可能有助于阐明“第三波”技术中的“活性成分”。

也许同样重要的是，SDT 背后的有机元理论带来了以人为本的敏感性和哲学，这本身对于有效实施新浪潮临床实践或任何真正以过程为导向的方法都很重要。以过程为导向的治疗方法不仅仅是一套技术，而且还需要以观点采择、促进和尊重自主为导向。理论的部分作用是指导临床医生在与客户的关系中制定、完善和实施这些方向。在这方面，SDT 中提出的心理学原则和价值观似乎与海耶斯和霍夫曼表达的许多“第三波”情感和价值观非常匹配，并被整合到与这一新的创新直接相关的概念框架中。移动。

自古典行为主义时代以来，人类动机的实证模型出现了“哥白尼式转向”——从将人视为外部偶然事件的棋子的模型转向关注人们内在行动能力的发展和支持。从这个角度来看，很高兴看到行为主义内部的这种转变远离海耶斯和霍夫曼所描述的“过于狭隘”的假设，并转向更加以人为中心的观点。鉴于 SDT 过去与行为主义者的冲突，“第三次浪潮”对真正以过程为导向的观点的开放性为交流方法、发现和实践提供了新的机会，并最终提供了更加趋同的临床科学。