A question of continuity: a self‐determination theory perspective on “third‐wave” behavioral theories and practices
Authors: Richard M. Ryan
Journal: World Psychiatry (2021)

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.