Twelve rather than three waves of cognitive behavior therapy allow a personalized treatment
Authors: Michael Linden
Journal: World Psychiatry (2022)

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.