The expression “third-wave cognitive behavior therapy (CBT)” has become a trade mark. It has been argued that it represents a new “process-based therapy”, which targets the relationship of the client to his/her own experiences in a transdiagnostic approach¹. However, a look at both history and present practice suggests that modern CBT encompasses at least a dozen “waves”, or basic theoretical concepts and treatment approaches. We sum­marize them herein.

First wave: classical learning theory. The development of CBT started with classical learning theory, including conditioning, habituation and systematic desensitization². Since then, dozens of technical variations of “exposure treatments” have been developed for transdiagnostic purposes, which show more or less the same therapeutic efficacy and are all part of this first theoretical framework, that can be summarized as the “first wave” of CBT.

Second wave: operant learning theory. Subsequently, it was recognized that behavior is also shaped by reinforcers, as described in operant learning theory, which can be called the “second wave” of CBT. Corresponding new treatment approaches were reinforcement schedules and behavioral activation, that have been used transdiagnostically with many technical variations until today³.

Third wave: coping and social learning theory. Reinforcers de­pend to some extent upon the coping skills of the individual, which is especially true in social encounters, as described in social learning and coping theories, including model learning theory. Relevant treatment approaches include many technical variations of social skills and assertiveness training⁴. Historically, “interpersonal therapy”, which also refers to social interaction models, was introduced at the same time.

Fourth wave: self-control. Coping and social competence require that the person has a sufficient capacity for self-control, which means to control oneself in the presence of adverse outer conditions under the influence of long-term reinforcers. Relevant treatment techniques are self-monitoring, self-instruction, internal dialogues, idealized self-imagination, and cognitive rehearsal, that are used transdiagnostically in anxiety, pain or “stress inoculation”⁵.

Fifth wave: attribution theory and cognitive theory. Even if a person has the capacity to control oneself, there is still the problem of when and why this is happening. Persons may have many skills, but may not use them because of dysfunctional expectations. This can be explained by “cognitive” models and attribution theories, which assume that it is not the environment per se that causes problems, but the person’s interpretation of the world. This may depend on cognitive schemata (content: e.g., belief in a just world) or processes (attribution style: e.g., generalization, magnification, minimization, emotional reasoning, worrying). “Cognitive therapy”, which has encompassed a large variety of techniques, aims to promote functional cognitions and cognitive processes⁶.

Sixth wave: emotion theory. Cognitions and behavior are also reversely shaped by emotions, as shown in experiments on motivation and state-dependent memory and reasoning. Relevant treatment strategies aim to promote development of various emo­tion regulation skills⁷.

Seventh wave: therapeutic relationship. While at the beginning of CBT the patient-therapist relationship did not play a major role, it became subsequently apparent that, also in this psychotherapy, patient participation, trust and relationship to the therapist are essential. There is not one uniform, but many types of relationships in CBT, depending on the needs of the person – i.e., warm or rational, demanding or permissive, structured or flexible. Therefore, mandatory self-experience has been introduced as part of training in CBT.

Eighth wave: disorder-specific therapy. As psychotherapy be­­came more widely used, and health insurance began to be in­­volved, proof of efficacy was needed with regard to specific dis­­orders. This was not only supported by clinicians, but also de­manded by the US Congress Office of Technology Assessment⁸. A wave of new studies referring to DSM criteria and using “disorder-specific therapy manuals” then emerged. Several alternative treatment methods were sometimes proposed for a given disor­der.

Ninth wave: acceptance theory. As there was no remission or cure in many disorders, further treatment goals were to help the patient accept what could not be changed and make the best of the situation. Treatments were developed such as mindfulness based cognitive therapy, or acceptance and commitment therapy¹, using strategies such as cognitive defusion, directing the attention to the present, value clarification, or action orientation.

Tenth wave: positive psychology and salutotherapy. A next step in dealing with chronic ailments came from positive psychology and salutogenesis. Relevant treatment approaches are euthymia therapy, well-being therapy, and salutotherapy. Patients are encouraged to identify moments of well-being, in contrast to negative states, and learn that well-being is not the result of external factors, but something that one is able to influence.

Eleventh wave: life span development and individual constitution. The “diathesis-stress model” showed that various individuals have different susceptibility to environmental influences. Thus, somatic and psychological constitution became a topic in CBT. This includes the assessment, by means of a “macro-analysis”, of the precursors and contingencies of the disorder from early childhood across the life span.

Twelfth wave: culture-sensitive psychotherapy. Therapists see patients with different cultural and religious backgrounds, which influence how they see the world, are controlled by their environment, and express mental distress. Recommendations for a culture-sensitive CBT include explicitly acknowledging the culture of the patient, developing disease concepts that fit into his/her culture, using metaphors from the patient’s world, and involving relatives or clergymen in decision-making.

The many theoretical foundations of CBT are integrated in a coherent type of psychotherapy through “behavior analysis”⁹. This looks at precursors and stimuli, cognitions, attributions, expectations, physiological and psychological constitution and skills, emotions, behavior, and consequences, which are all interrelated. All this results in a personalized appraisal of the patient’s problems, which then guides an individually tailored treatment process, independent of diagnostic labels. CBT can be therefore considered a “precision therapy”. All techniques of all “waves” are used depending on the results of the behavior analysis, which distinguishes CBT from other types of psychotherapy.

Thus, a cognitive behavior therapist is somebody who is well versed in all theories which underlie CBT, masters the spectrum of therapeutic techniques derived thereof, and can integrate them in an individual model, after having conducted a competent behavior analysis.

“第三波认知行为疗法（CBT）”这一表述已成为商标。有人认为，它代表了一种新的“基于过程的疗法”，其目标是客户与他/她在跨诊断方法中的自身经历的关系¹。然而，从历史和现在的实践来看，现代 CBT 至少包含十几个“浪潮”，或基本的理论概念和治疗方法。我们在此对其进行总结。

第一波：经典学习理论。CBT 的发展始于经典学习理论，包括条件反射、习惯化和系统脱敏²。从那时起，为跨诊断目的开发了数十种“暴露治疗”技术变体，它们或多或少显示出相同的治疗效果，都是第一个理论框架的一部分，可以概括为 CBT 的“第一波” .

第二波：操作学习理论。随后，人们认识到行为也受到强化物的影响，如操作性学习理论所述，可以称为 CBT 的“第二波”。相应的新治疗方法是强化计划和行为激活，直到今天³已被用于跨诊断与许多技术变化。

第三波：应对与社会学习理论。强化物在一定程度上取决于个人的应对技能，这在社会遭遇中尤其如此，正如社会学习和应对理论（包括模型学习理论）所描述的那样。相关的治疗方法包括社交技能和自信训练⁴的许多技术变化。历史上，“人际治疗”，也指社会交往模式，是同时引入的。

第四波：自我控制。应对和社会能力要求人有足够的自我控制能力，这意味着在长期强化物的影响下，在不利的外部条件存在的情况下控制自己。相关的治疗技术是自我监控、自我指导、内部对话、理想化的自我想象和认知排练，这些技术被用于焦虑、疼痛或“压力接种” ⁵的跨诊断。

第五波：归因理论和认知理论。即使一个人有能力控制自己，仍然存在何时以及为什么会发生这种情况的问题。人们可能拥有许多技能，但可能会因为不正常的期望而无法使用它们。这可以通过“认知”模型和归因理论来解释，它们假设导致问题的不是环境本身，而是个人对世界的解释。这可能取决于认知图式（内容：例如，对公正世界的信念）或过程（归因方式：例如，概括、放大、最小化、情感推理、担忧）。“认知疗法”包含多种技术，旨在促进功能性认知和认知过程⁶。

第六波：情绪论。认知和行为也被情绪反向塑造，如动机和状态依赖性记忆和推理实验所示。相关治疗策略旨在促进各种情绪调节技能的发展⁷。

第七波：治疗关系。虽然在 CBT 开始时患者与治疗师的关系并没有发挥主要作用，但随后很明显，在这种心理治疗中，患者的参与、信任和与治疗师的关系也是必不可少的。CBT 中不存在统一的关系，而是多种类型的关系，这取决于人的需求——即热情或理性、要求或宽容、结构化或灵活。因此，强制性的自我体验已被引入作为 CBT 培训的一部分。

第八波：疾病特异性治疗。随着心理治疗的应用越来越广泛，并且开始涉及健康保险，需要对特定疾病进行疗效证明。这不仅得到了临床医生的支持，也得到了美国国会技术评估办公室的要求⁸。随后出现了一波参考 DSM 标准并使用“特定疾病治疗手册”的新研究。有时针对给定的疾病提出了几种替代治疗方法。

第九波：接受理论。由于许多疾病没有缓解或治愈，进一步的治疗目标是帮助患者接受无法改变的事情并充分利用这种情况。开发了诸如基于正念的认知疗法或接受和承诺疗法¹等治疗方法，使用诸如认知解离、将注意力引导到现在、价值澄清或行动导向等策略。

第十波：积极心理学和问候疗法。处理慢性疾病的下一步来自积极心理学和salutogenesis。相关的治疗方法是 euthymia 疗法、幸福疗法和 salutotherapy。鼓励患者识别与消极状态相反的幸福时刻，并了解幸福不是外部因素的结果，而是人们能够影响的东西。

第十一波：寿命发展与个人体质。“素质-压力模型”表明，不同的个体对环境影响的敏感性不同。因此，身体和心理构成成为CBT中的一个话题。这包括通过“宏观分析”对儿童早期疾病在整个生命周期中的前兆和突发事件进行评估。

第十二波：文化敏感心理治疗。治疗师会看到具有不同文化和宗教背景的患者，这会影响他们看待世界的方式，受环境控制，并表达精神痛苦。对文化敏感的 CBT 的建议包括明确承认患者的文化，发展适合他/她的文化的疾病概念，使用来自患者世界的隐喻，以及让亲属或神职人员参与决策。

CBT 的许多理论基础通过“行为分析” ⁹整合到一种连贯的心理治疗中。这着眼于前兆和刺激、认知、归因、期望、生理和心理构成和技能、情绪、行为和后果，这些都是相互关联的。所有这些都会导致对患者问题的个性化评估，然后指导个性化定制的治疗过程，独立于诊断标签。因此，CBT 可以被认为是一种“精准疗法”。所有“波”的所有技术都根据行为分析的结果使用，这将 CBT 与其他类型的心理治疗区分开来。

因此，认知行为治疗师是精通 CBT 基础的所有理论，掌握由此衍生的治疗技术范围，并在进行了有效的行为分析后能够将它们整合到个人模型中的人。