- Email: [email protected]
The Science of CBT: Toward a Metacognitive Model of Change?
Behavior Therapy 44 (2013) 224 – 227
www.elsevier.com/locate/bt
COMMENTARY
The Science of CBT: Toward a Metacognitive Model of Change? Keith S. Dobson University of Calgary
This article supports several aspects of the arguments by Hofmann, Asmundson, and Beck (2013–this issue) about the scientific basis of cognitive-behavioral therapy (CBT), for example, that CBT has a strong evidence base, and that studies of the mechanisms of change are warranted. This response discusses growth within the broad field of CBT, as well as the diverse research methods that are needed to explore both clinical efficacy and treatment mechanism questions. It is suggested that the field of CBT may be approaching a shift in emphasis from cognitive to metacognitive assessment and interventions. The article concludes with a statement of general support for further development of the field of CBT.
Keywords: cognitive behavioral therapy; cognitive mediation; randomized clinical trial; cognitive science
HOFMANN, ASMUNDSON, & BECK (2013–this issue) present a cogent set of arguments about the scientific basis of cognitive-behavioral therapy (CBT), and also nicely contrast the tenets among different models of CBT. In this response, I discuss the growth in the broad field of CBT, as well as research methods to explore clinical efficacy and treatment mechanism questions. I then suggest detail that the field of CBT may be approaching a shift in emphasis from cognitive to metacognitive assessment and interventions.
The Broad (and Expanding) Field of CBT Hofmann, Asmundson, & Beck (2013–this issue) define CBT as “a family of interventions” that are not tied to a particular philosophical tradition but are loosely rationalistic and empiricist in back-
Address correspondence to Keith S. Dobson, Department of Psychology, University of Calgary, 2500 University Drive, NW, Calgary, Alberta T2N 1N4; e-mail: [email protected]. 0005-7894/44/224–227/$1.00/0 © 2011 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.
ground. There is little doubt that CBT comprises several diverse models, and it is an approach that is expanding, as discussed below. There is good reason, however, to differ with the position that no philosophical tradition underlies much of CBT. For example, as one of the key originators of the approach, Ellis was explicitly philosophical in the development of his approach, and drew on stoic and rationalist philosophical traditions (Dryden, David, & Ellis, 2010). Similarly, Beck has identified that the basic tenets of cognitive therapy (CT) are consistent with rationalist philosophy (although they do also acknowledge some heritage from both psychodynamic therapy and phenomenological principles; Beck, Rush, Shaw, & Emery, 1979; see also Beck, 1970). Several descriptions of CBT highlight the rationalist basis of the idea of cognitive distortions, and the corollary assumption that mental health is at least in part defined by the correspondence of a person's thoughts and external reality (cf. Held, 1995), or what has been called a realist assumption (Dobson & Dobson, 2009). Put otherwise, adaptation reflects how well a person can recognize and cope with the demands of his or her environment, and cope with external and internal stressors. The ideas that cognitive distortions are markers of mental disorder and that correction of cognitive distortions is therapeutic have been cornerstones of CBT theory and practice. The realist assumption, and the interventions that derive from this assumption do not reflect the sum of CBT thinking with respect to human processes. CBT models also recognize that humans develop core beliefs, schemas, assumptions, and attitudes that do not necessarily correspond with reality but nonetheless provide an adaptive sense of identity and coherence. Some of the methods of CBT focus on the coherence of self-identity and stability of interpersonal relations, as mechanisms to support the patient and to enhance mental health. Thus,
the science of cbt CBT contains elements of both correspondence and coherence aspects of mental health. Various books describe CBT as technically eclectic, which it certainly is. There are an enormous number of interventions that have been developed within this framework (McMullin, 2000; O'Donohue & Fisher, 2009). There are also numerous distinct approaches within CBT, including but not limited to rational emotive behavior therapy (REBT), CT, stress inoculation training, problem-solving therapy, schema therapy, and acceptance and commitment therapy (Dobson, 2010). Although each of these approaches has its own unique elements, they all subscribe to the three essential elements of CBT, which have been stated (Dobson & Dozois, 2010, p. 4) as: 1. Cognitive activity affects behavior. 2. Cognitive activity may be monitored and altered. 3. Desired behavior change may be affected through cognitive change. All of the above-listed CBT approaches contain these three aspects in their models, and they are reflected in such treatment elements as cognitive assessment, reflection about experience, assignment of tasks or homework to collect more information about the linkage between thought and action, and intentional plans to modify thoughts and behavior. All CBT approaches also employ and evaluate the adaptiveness of thought and behavior with the patient's world, often as indexed by emotional distress and/or problems in functioning.
Research of Efficacy and Mechanisms of CBT Hofmann, Asmundson, & Beck (2013–this issue) provide an excellent summary of the evidence related to CBT. It can be stated with some confidence that CBT “works,” and that for a number of clinical problems it is the treatment of choice (Butler, Chapman, Forman, & Beck, 2006; Chambless et al., 1998; Hofmann & Smits, 2008). In a recent review of the absolute efficacy (compared to no treatment, or wait-list) and relative efficacy (compared to another active psychotherapy and/or pharmacotherapy) of CBT, Epp and Dobson (2010) also found that CBT has strong evidence to support its claim to efficacy. Thus, while more data is needed in many areas and further outcome trials are warranted, CBT represents a major accomplishment for the mental health field. Even as the evidence related to CBT's efficacy accumulates, questions remain. These center around two major questions. The first question relates to which individual difference variables (also
225
called “aptitudes”) might moderate treatment response, or what has been called the “aptitude by treatment interaction” (Haaga & Stiles, 2000) question. This important issue examines which patient characteristics moderate outcome, and can potentially identify which treatment is optimal for people with identifiable characteristics. As individual differences are widely recognized on many dimensions, the accumulation of this evidence will serve to enhance patient care. It may also be possible through such research to identify treatment parameters or methods that work better in some groups, and thus lead to the recognition of more broadly indicated interventions with those groups. In many respects, however, this is a technical question, since this type of research does not fundamentally contribute to better understanding of how treatment by aptitude interactions emerge. The second major question in the field therefore relates to mechanisms of change, or what are evaluated as mediators and moderators (Kraemer, Wilson, Fairburn, & Agras, 2002). If we can understand the treatment parameters or patient processes that presage clinical outcome, it may be possible to refine our models and methods of treatment, to maximize efficiency and clinical outcomes. The randomized clinical trial (RCT) has become the standard for the evaluation of treatment efficacy, and RCT technology is ideally suited for this purpose (Nezu & Nezu, 2007). That said, RCTs are best able to address the question of whether a treatment technology has an associated outcome. In the case of CBT, which is technically eclectic, the field is often left with the limited ability to claim whether a treatment package does or does not have certain definable outcomes. As noted by Hofmann, Asmundson, & Beck (2013–this issue), however, even component analyses can at best address the question of whether certain elements of a treatment have more or less outcome than others; they do not address the issue of how that change comes about. In order to pursue questions related to mechanisms of change, studies are needed to examine the cognitive, behavioral, emotional, and possibly physiological processes that precede, co-occur with, and follow identifiable CBT methods. Most clinical theorists hypothesize that their intervention instantiates a particular mechanism of change. It is possible, however, that different CBT models and diverse therapist activities actually lead to their outcomes through patient mechanisms that are more similar than distinct. As an example, there is mounting evidence that behavioral and CBT approaches to depression have comparable outcomes (Epp & Dobson, 2010; Gloaguen, Cottraux, Cucherat, & Blackburn, 1998). Do these treatments
226
dobson
have different patient processes? Patients who receive behavioral activation (BA) treatment (Martell, Addis, & Jacobson, 2001) will obviously be aware that they are in treatment. They make conscious choices about what behaviors they will engage in, and they observe their own behavior and its effects in their social environment. As such, they are actively processing and reflecting on treatment changes. Patient who receive CT, in turn, also reflect on their behavioral choices, examine the evidence that their thoughts are in line with their behavior and/or external events, and choose different more adaptive behaviors to achieve life goals. Thus, from a patient's perspective, it is quite possible that both BA and CT do much the same things, albeit with a different focus. Maybe common patient experience explains why the limited data about process variables measured at the end of these treatments generally do not reveal differences (e.g., Dimidjian, et al, 2006). As a bit of a side aspect of their paper, Hofmann, Asmundson, & Beck (2013–this issue) note that cognitive neuroscience may help to provide a common pathway to change. My own perspective on this point is not so sanguine. We have known for a long time that psychological processes can affect physiological states, in much the same way that physiological states can serve as setting conditions for cognitive and other processes (e.g., mooddependent memory effects). Humans are fundamentally biopsychosocial animals, and “ultimate” models of functioning will need to incorporate all elements of these multidirectional processes. The field of CBT, however, does not need demonstrable brain changes to legitimize its cognitive, behavioral, and emotional outcomes. Indeed, while such evidence may help to legitimize CBT in some respects (Beauregard, 2007; Lieberman, 2007), it might even be a distraction to pursue these effects.
The Move to Metacognition One of the recent shifts in CBT has been the movement toward a focus on metacognition, or thinking about thinking and experience. Of course, in some respects, CBT has always had metacognitive elements. The completion a CT thought diary, for example, requires the patient to step back from momentary experience, and to observe and record it. The process of rational disputation seen in REBT requires the ability to name and examine the utility of various belief systems. Problem-solving therapy explicitly invites the patient to step back from his or her automatic and reflexive problem-solving strategies, to conceptualize alternative approaches to life's problems. Schema-focused work also examines not just momentary experience but the larger
cognitive–affective–behavioral frameworks that are used by patients to structure their lives. Thus, metacognitive aspects are included in most of the extant CBT approaches. In general, though, these metacognitive elements are in aid of change, of looking at these cognitive-behavioral patterns to find alternative, more evidential and adaptive ways to function. Recently, however, there is an alternative metacognitive perspective that has emerged. This approach focuses on the recognition of thoughts and experience, but then focuses on acceptance, rather than change (Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Jacobson & Christensen, 1996). Thus, in mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2001), a prevention of relapse in depression program, patients are trained to be aware of their experiences (thoughts, feelings, sensations, behavior), and then to “sit with” or simply attend to these experiences, rather than modify or shut them down. Similar to acceptance and commitment therapy (Hayes et al., 2006), there is an acknowledgment that life sometimes hurts, but that ongoing resistance toward and struggle against problems may not sometimes be the most adaptive strategy. Rather, an alternative metacognition may be to accept that things are difficult, and then choose to do something different in any event. The focus on acceptance-orientated interventions in CBT is in its early stages (Fruzzetti & Erikson, 2010). The field certainly needs more efficacy data in this domain, to know whether the outcomes of these models parallel or perhaps even exceed more standard CBT models (Öst, 2008). If so, then an even greater armamentarium of interventions will exist. Further, though, it may be that treatment by aptitude interactions may exist for different CBTs, from a metacognitive perspective. For example, it may be that more traditional change-oriented CBTs will have greater acceptability and better outcome for patients with more recent and/or acute problems. In contrast, acceptance-oriented CBT models may be more acceptable and have better outcome for patients who have more chronic or longstanding problems; where the patients in effect need to learn to live with some aspects of the disorder or problem, even while they improve their functioning to their optimum.
In Closing As a final thought, I want to underscore the enthusiasm that Hofmann, Asmundson, & Beck (2013–this issue) expressed in their article. As they say, CBT is a major success story. Further, it is likely to stay so, as long as the theorists, researchers, and clinicians continue to examine and evaluate the
the science of cbt evidence base, conceptual models, and meditational pathways associated with these approaches. For one, I am not at all disconcerted by the expansion of CBT into “third wave” (Hofmann & Asmundson, 2008) or other paradigms, as long as the field can appropriately debate and discuss the expansion, with a clear reference to the evidence. Our ultimate goal is the welfare of the patients we serve, and if we can devise a superior intervention, or an intervention that better fits the cognitive world of some patients, we likely should get on with that process. References Beauregard, M. (2007). Mind does really matter: Evidence from neuroimaging studies of emotional self-regulation, psychotherapy, and placebo effect. Progress in Neurobiology, 81, 218–236. Beck, A. T. (1970). Cognitive therapy: Nature and relation to behaviour therapy. Behavior Therapy, 1, 184–200. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). The cognitive therapy of depression. New York: Guilford Press. Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26, 17–31. Chambless, D. L., Baker, M. J., Baucom, D. H., Beutler, L. E., Calhoun, K. S., Crits-Christoph, P., . . . McCurry, S. (1998). Update on empirically validated therapies, II. Clinical Psychologist, 51, 3–16. Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., Addis, M. E., . . . Jacobson, N. S. (2006). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of Consulting and Clinical Psychology, 74, 658–670. Dobson, D. J. A., & Dobson, K. S. (2009). Evidence-based practice of cognitive-behavior therapy. New York: Guilford Press. Dobson, K. S. (Ed.). (2010). Handbook of cognitive-behavioral therapies (3rd ed.). New York: Guilford Press. Dobson, K. S., & Dozois, D. (2010). Historical and philosophical bases of the cognitive-behavioral therapies. In K. S. Dobson (Ed.), Handbook of cognitive-behavioral therapies (3rd ed., pp. 3–38). New York: Guilford Press. Dryden, W., David, D., & Ellis, A. (2010). Rational emotive behavior therapy. In K. S. Dobson (Ed.), Handbook of cognitive-behavioral therapies (3rd ed., pp. 226–276). New York: Guilford Press. Epp, A. M., & Dobson, K. S. (2010). The evidence base for cognitive-behavioral therapy. In K. S. Dobson (Ed.), Handbook of cognitive-behavioral therapies (3rd ed., pp. 39–73). New York: Guilford Press. Fruzzetti, A. E., & Erikson, K. R. (2010). Mindfulness and acceptance interventions in cognitive behavior therapy. In
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K. S. Dobson (Ed.), Handbook of cognitive-behavioral therapies (3rd ed., pp. 347–374). New York: Guilford Press. Gloaguen, V., Cottraux, J., Cucherat, M., & Blackburn, I. (1998). A meta-analysis of the effects of cognitive therapy in depressed patients. Journal of Affective Disorders, 49, 59–72. Haaga, D. A., & Stiles, W. B. (2000). Randomized clinical trials in psychotherapy research: Methodology, design and evaluation. In C. R. Snyder & R. E. Ingram (Ed.), Handbook of psychological change: Psychotherapy processes and practices for the 21st century (pp. 14–39). New York: Wiley. Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes, and outcomes. Behaviour Research and Therapy, 44, 1–26. Held, B. S. (1995). Back to reality: A critique of postmodern theory in psychotherapy. New York: Norton. Hofmann, S. G., & Asmundson, G. J. (2008). Acceptance and mindfulness-based therapy: New wave or old hat? Clinical Psychology Review, 28, 1–16. Hofmann, S. G., Asmundson, G. J. G., & Beck, A. T. (2013). The Science of Cognitive Therapy. Behavior Therapy, 44, 199–212 (this issue). Hofmann, S. G., & Smits, J. A. J. (2008). Cognitive-behavioral therapy for adult anxiety disorders: A meta-analysis of randomized placebo-controlled trials. Journal of Clinical Psychiatry, 69, 621–632. Jacobson, N. S., & Christensen, A. (1996). Acceptance and change in couple therapy: A therapist's guide to transforming relationships. New York: Norton. Kraemer, H. C., Wilson, T., Fairburn, C. G., & Agras, W. S. (2002). Mediators and moderators of treatment effects in randomized clinical trials. Archives of General Psychiatry, 59, 877–883. Lieberman, M. D. (2007). Social cognitive neuroscience: A review of core processes. Annual Review of Psychology, 58, 259–289. Martell, C., Addis, M., & Jacobson, N. (2001). Depression in context: Strategies for guided action. New York: Norton. McMullin, R. E. (2000). The new handbook of cognitive therapy techniques. New York: Norton. Nezu, A. M., & Nezu, C. M. (Eds.). (2007). Evidence-based outcome research: A practical guide to conducting randomized controlled trials for psychosocial interventions New York: Oxford University Press. O'Donohue, W. T., & Fisher, J. E. (Eds.). (2009). General principles and empirically supported techniques of cognitive behaviour therapy. Hoboken, NJ: Wiley. Öst, L. G. (2008). Efficacy of the third wave of behavioral therapies: A systematic review and meta-analysis. Behaviour Research and Therapy, 46, 296–321. Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2001). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York: Guilford Press.
R E C E I V E D : August 4, 2009 A C C E P T E D : August 4, 2009 Available online 6 June 2011
www.elsevier.com/locate/bt
COMMENTARY
The Science of CBT: Toward a Metacognitive Model of Change? Keith S. Dobson University of Calgary
This article supports several aspects of the arguments by Hofmann, Asmundson, and Beck (2013–this issue) about the scientific basis of cognitive-behavioral therapy (CBT), for example, that CBT has a strong evidence base, and that studies of the mechanisms of change are warranted. This response discusses growth within the broad field of CBT, as well as the diverse research methods that are needed to explore both clinical efficacy and treatment mechanism questions. It is suggested that the field of CBT may be approaching a shift in emphasis from cognitive to metacognitive assessment and interventions. The article concludes with a statement of general support for further development of the field of CBT.
Keywords: cognitive behavioral therapy; cognitive mediation; randomized clinical trial; cognitive science
HOFMANN, ASMUNDSON, & BECK (2013–this issue) present a cogent set of arguments about the scientific basis of cognitive-behavioral therapy (CBT), and also nicely contrast the tenets among different models of CBT. In this response, I discuss the growth in the broad field of CBT, as well as research methods to explore clinical efficacy and treatment mechanism questions. I then suggest detail that the field of CBT may be approaching a shift in emphasis from cognitive to metacognitive assessment and interventions.
The Broad (and Expanding) Field of CBT Hofmann, Asmundson, & Beck (2013–this issue) define CBT as “a family of interventions” that are not tied to a particular philosophical tradition but are loosely rationalistic and empiricist in back-
Address correspondence to Keith S. Dobson, Department of Psychology, University of Calgary, 2500 University Drive, NW, Calgary, Alberta T2N 1N4; e-mail: [email protected]. 0005-7894/44/224–227/$1.00/0 © 2011 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.
ground. There is little doubt that CBT comprises several diverse models, and it is an approach that is expanding, as discussed below. There is good reason, however, to differ with the position that no philosophical tradition underlies much of CBT. For example, as one of the key originators of the approach, Ellis was explicitly philosophical in the development of his approach, and drew on stoic and rationalist philosophical traditions (Dryden, David, & Ellis, 2010). Similarly, Beck has identified that the basic tenets of cognitive therapy (CT) are consistent with rationalist philosophy (although they do also acknowledge some heritage from both psychodynamic therapy and phenomenological principles; Beck, Rush, Shaw, & Emery, 1979; see also Beck, 1970). Several descriptions of CBT highlight the rationalist basis of the idea of cognitive distortions, and the corollary assumption that mental health is at least in part defined by the correspondence of a person's thoughts and external reality (cf. Held, 1995), or what has been called a realist assumption (Dobson & Dobson, 2009). Put otherwise, adaptation reflects how well a person can recognize and cope with the demands of his or her environment, and cope with external and internal stressors. The ideas that cognitive distortions are markers of mental disorder and that correction of cognitive distortions is therapeutic have been cornerstones of CBT theory and practice. The realist assumption, and the interventions that derive from this assumption do not reflect the sum of CBT thinking with respect to human processes. CBT models also recognize that humans develop core beliefs, schemas, assumptions, and attitudes that do not necessarily correspond with reality but nonetheless provide an adaptive sense of identity and coherence. Some of the methods of CBT focus on the coherence of self-identity and stability of interpersonal relations, as mechanisms to support the patient and to enhance mental health. Thus,
the science of cbt CBT contains elements of both correspondence and coherence aspects of mental health. Various books describe CBT as technically eclectic, which it certainly is. There are an enormous number of interventions that have been developed within this framework (McMullin, 2000; O'Donohue & Fisher, 2009). There are also numerous distinct approaches within CBT, including but not limited to rational emotive behavior therapy (REBT), CT, stress inoculation training, problem-solving therapy, schema therapy, and acceptance and commitment therapy (Dobson, 2010). Although each of these approaches has its own unique elements, they all subscribe to the three essential elements of CBT, which have been stated (Dobson & Dozois, 2010, p. 4) as: 1. Cognitive activity affects behavior. 2. Cognitive activity may be monitored and altered. 3. Desired behavior change may be affected through cognitive change. All of the above-listed CBT approaches contain these three aspects in their models, and they are reflected in such treatment elements as cognitive assessment, reflection about experience, assignment of tasks or homework to collect more information about the linkage between thought and action, and intentional plans to modify thoughts and behavior. All CBT approaches also employ and evaluate the adaptiveness of thought and behavior with the patient's world, often as indexed by emotional distress and/or problems in functioning.
Research of Efficacy and Mechanisms of CBT Hofmann, Asmundson, & Beck (2013–this issue) provide an excellent summary of the evidence related to CBT. It can be stated with some confidence that CBT “works,” and that for a number of clinical problems it is the treatment of choice (Butler, Chapman, Forman, & Beck, 2006; Chambless et al., 1998; Hofmann & Smits, 2008). In a recent review of the absolute efficacy (compared to no treatment, or wait-list) and relative efficacy (compared to another active psychotherapy and/or pharmacotherapy) of CBT, Epp and Dobson (2010) also found that CBT has strong evidence to support its claim to efficacy. Thus, while more data is needed in many areas and further outcome trials are warranted, CBT represents a major accomplishment for the mental health field. Even as the evidence related to CBT's efficacy accumulates, questions remain. These center around two major questions. The first question relates to which individual difference variables (also
225
called “aptitudes”) might moderate treatment response, or what has been called the “aptitude by treatment interaction” (Haaga & Stiles, 2000) question. This important issue examines which patient characteristics moderate outcome, and can potentially identify which treatment is optimal for people with identifiable characteristics. As individual differences are widely recognized on many dimensions, the accumulation of this evidence will serve to enhance patient care. It may also be possible through such research to identify treatment parameters or methods that work better in some groups, and thus lead to the recognition of more broadly indicated interventions with those groups. In many respects, however, this is a technical question, since this type of research does not fundamentally contribute to better understanding of how treatment by aptitude interactions emerge. The second major question in the field therefore relates to mechanisms of change, or what are evaluated as mediators and moderators (Kraemer, Wilson, Fairburn, & Agras, 2002). If we can understand the treatment parameters or patient processes that presage clinical outcome, it may be possible to refine our models and methods of treatment, to maximize efficiency and clinical outcomes. The randomized clinical trial (RCT) has become the standard for the evaluation of treatment efficacy, and RCT technology is ideally suited for this purpose (Nezu & Nezu, 2007). That said, RCTs are best able to address the question of whether a treatment technology has an associated outcome. In the case of CBT, which is technically eclectic, the field is often left with the limited ability to claim whether a treatment package does or does not have certain definable outcomes. As noted by Hofmann, Asmundson, & Beck (2013–this issue), however, even component analyses can at best address the question of whether certain elements of a treatment have more or less outcome than others; they do not address the issue of how that change comes about. In order to pursue questions related to mechanisms of change, studies are needed to examine the cognitive, behavioral, emotional, and possibly physiological processes that precede, co-occur with, and follow identifiable CBT methods. Most clinical theorists hypothesize that their intervention instantiates a particular mechanism of change. It is possible, however, that different CBT models and diverse therapist activities actually lead to their outcomes through patient mechanisms that are more similar than distinct. As an example, there is mounting evidence that behavioral and CBT approaches to depression have comparable outcomes (Epp & Dobson, 2010; Gloaguen, Cottraux, Cucherat, & Blackburn, 1998). Do these treatments
226
dobson
have different patient processes? Patients who receive behavioral activation (BA) treatment (Martell, Addis, & Jacobson, 2001) will obviously be aware that they are in treatment. They make conscious choices about what behaviors they will engage in, and they observe their own behavior and its effects in their social environment. As such, they are actively processing and reflecting on treatment changes. Patient who receive CT, in turn, also reflect on their behavioral choices, examine the evidence that their thoughts are in line with their behavior and/or external events, and choose different more adaptive behaviors to achieve life goals. Thus, from a patient's perspective, it is quite possible that both BA and CT do much the same things, albeit with a different focus. Maybe common patient experience explains why the limited data about process variables measured at the end of these treatments generally do not reveal differences (e.g., Dimidjian, et al, 2006). As a bit of a side aspect of their paper, Hofmann, Asmundson, & Beck (2013–this issue) note that cognitive neuroscience may help to provide a common pathway to change. My own perspective on this point is not so sanguine. We have known for a long time that psychological processes can affect physiological states, in much the same way that physiological states can serve as setting conditions for cognitive and other processes (e.g., mooddependent memory effects). Humans are fundamentally biopsychosocial animals, and “ultimate” models of functioning will need to incorporate all elements of these multidirectional processes. The field of CBT, however, does not need demonstrable brain changes to legitimize its cognitive, behavioral, and emotional outcomes. Indeed, while such evidence may help to legitimize CBT in some respects (Beauregard, 2007; Lieberman, 2007), it might even be a distraction to pursue these effects.
The Move to Metacognition One of the recent shifts in CBT has been the movement toward a focus on metacognition, or thinking about thinking and experience. Of course, in some respects, CBT has always had metacognitive elements. The completion a CT thought diary, for example, requires the patient to step back from momentary experience, and to observe and record it. The process of rational disputation seen in REBT requires the ability to name and examine the utility of various belief systems. Problem-solving therapy explicitly invites the patient to step back from his or her automatic and reflexive problem-solving strategies, to conceptualize alternative approaches to life's problems. Schema-focused work also examines not just momentary experience but the larger
cognitive–affective–behavioral frameworks that are used by patients to structure their lives. Thus, metacognitive aspects are included in most of the extant CBT approaches. In general, though, these metacognitive elements are in aid of change, of looking at these cognitive-behavioral patterns to find alternative, more evidential and adaptive ways to function. Recently, however, there is an alternative metacognitive perspective that has emerged. This approach focuses on the recognition of thoughts and experience, but then focuses on acceptance, rather than change (Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Jacobson & Christensen, 1996). Thus, in mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2001), a prevention of relapse in depression program, patients are trained to be aware of their experiences (thoughts, feelings, sensations, behavior), and then to “sit with” or simply attend to these experiences, rather than modify or shut them down. Similar to acceptance and commitment therapy (Hayes et al., 2006), there is an acknowledgment that life sometimes hurts, but that ongoing resistance toward and struggle against problems may not sometimes be the most adaptive strategy. Rather, an alternative metacognition may be to accept that things are difficult, and then choose to do something different in any event. The focus on acceptance-orientated interventions in CBT is in its early stages (Fruzzetti & Erikson, 2010). The field certainly needs more efficacy data in this domain, to know whether the outcomes of these models parallel or perhaps even exceed more standard CBT models (Öst, 2008). If so, then an even greater armamentarium of interventions will exist. Further, though, it may be that treatment by aptitude interactions may exist for different CBTs, from a metacognitive perspective. For example, it may be that more traditional change-oriented CBTs will have greater acceptability and better outcome for patients with more recent and/or acute problems. In contrast, acceptance-oriented CBT models may be more acceptable and have better outcome for patients who have more chronic or longstanding problems; where the patients in effect need to learn to live with some aspects of the disorder or problem, even while they improve their functioning to their optimum.
In Closing As a final thought, I want to underscore the enthusiasm that Hofmann, Asmundson, & Beck (2013–this issue) expressed in their article. As they say, CBT is a major success story. Further, it is likely to stay so, as long as the theorists, researchers, and clinicians continue to examine and evaluate the
the science of cbt evidence base, conceptual models, and meditational pathways associated with these approaches. For one, I am not at all disconcerted by the expansion of CBT into “third wave” (Hofmann & Asmundson, 2008) or other paradigms, as long as the field can appropriately debate and discuss the expansion, with a clear reference to the evidence. Our ultimate goal is the welfare of the patients we serve, and if we can devise a superior intervention, or an intervention that better fits the cognitive world of some patients, we likely should get on with that process. References Beauregard, M. (2007). Mind does really matter: Evidence from neuroimaging studies of emotional self-regulation, psychotherapy, and placebo effect. Progress in Neurobiology, 81, 218–236. Beck, A. T. (1970). Cognitive therapy: Nature and relation to behaviour therapy. Behavior Therapy, 1, 184–200. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). The cognitive therapy of depression. New York: Guilford Press. Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26, 17–31. Chambless, D. L., Baker, M. J., Baucom, D. H., Beutler, L. E., Calhoun, K. S., Crits-Christoph, P., . . . McCurry, S. (1998). Update on empirically validated therapies, II. Clinical Psychologist, 51, 3–16. Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., Addis, M. E., . . . Jacobson, N. S. (2006). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of Consulting and Clinical Psychology, 74, 658–670. Dobson, D. J. A., & Dobson, K. S. (2009). Evidence-based practice of cognitive-behavior therapy. New York: Guilford Press. Dobson, K. S. (Ed.). (2010). Handbook of cognitive-behavioral therapies (3rd ed.). New York: Guilford Press. Dobson, K. S., & Dozois, D. (2010). Historical and philosophical bases of the cognitive-behavioral therapies. In K. S. Dobson (Ed.), Handbook of cognitive-behavioral therapies (3rd ed., pp. 3–38). New York: Guilford Press. Dryden, W., David, D., & Ellis, A. (2010). Rational emotive behavior therapy. In K. S. Dobson (Ed.), Handbook of cognitive-behavioral therapies (3rd ed., pp. 226–276). New York: Guilford Press. Epp, A. M., & Dobson, K. S. (2010). The evidence base for cognitive-behavioral therapy. In K. S. Dobson (Ed.), Handbook of cognitive-behavioral therapies (3rd ed., pp. 39–73). New York: Guilford Press. Fruzzetti, A. E., & Erikson, K. R. (2010). Mindfulness and acceptance interventions in cognitive behavior therapy. In
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R E C E I V E D : August 4, 2009 A C C E P T E D : August 4, 2009 Available online 6 June 2011