Variation, selection and retention: the evolution of process of change

Hayes and Hofmann¹ argue for the value of “third‐wave” cognitive behavioral therapies (CBTs) – with which I heartily agree – and call for a renewed focus on targeting an expanded range of processes of change. They highlight five features of “third‐wave” therapies: a) a focus on context and function; b) the view that new mod­els and meth­ods should build on other strands of CBT; c) a focus on broad and flexible repertoires; d) applying processes to the clinician; and e) expanding into more complex issues that historically were addressed by humanistic, existential and dynamic perspectives.

Variation is always to be desired and, if we have learned anything over the last century, it is that “one size does not fit all”. We have made some marvelous strides in the field (we have doubled the efficacy of treatments for depression since the 1970s), but we are only about halfway to where we want to be. Midway through the second year of my “internship” at the University of Pennsylvania, in 1976, I was called into the office of the associate director of the training program and told “Steve, we have a problem”. When I asked what the problem was, he told me that I was discharging my patients too fast. When I said that they were better, he told me that what I was observing was a “flight into health” and that I risked pushing my patients into psychotic decompensations if I insisted on treating their symptoms. We now know that any of several different types of psychotherapy are as efficacious as antidepressants for depression, and that both cognitive therapy (“second wave”) and perhaps behavior­al activation (“third wave”) have enduring effects that medications lack.

Nothing works for everyone, and the more different “arrows in our quiver”, the better for all. We now have tools at our disposal that can tell us what works best for whom, and the early indications are that some people will respond to one treatment who will not respond to another². Hayes and Hofmann criticize the application of treatment packages to diagnostic categories, and I appreciate their critique. That being said, two‐thirds of the patients meeting criteria for major depressive disorder in the trials that I do also meet criteria for other Axis I disorders, and half meet criteria for at least one Axis II disorder. While I do attend to the content of my patients’ beliefs (more than their context) and often encourage them to use their own behaviors to test their accuracy, what I do and how I do it varies from one patient to the next. Most patients see themselves as either unlovable or incompetent, but precisely how that came to be and what tests they find compelling varies across patients. If Hayes and Hofmann can help lay that out, I am all ears.

I am a huge fan of D. Clark and his colleagues at Oxford and wrote a paper recently in which I speculated about how it is that they have been so successful in the approaches they have developed³. Clark essentially cured panic disorders, and a recent network meta‐analysis found his approach to individual cognitive therapy to be the single most efficacious treatment for social anxiety⁴. He also found time to reshape the mental health care system in the UK to increase access to empirically supported treatments⁵. His partner A. Ehlers has a “kinder gentler” cognitive approach to the treatment of post‐traumatic stress disorder that is as efficacious as prolonged exposure, with considerably less attrition. P. Salkovskis knows more about the treatment of obsessive‐compulsive disorder than anyone else I am aware of and would be my “go to” person for a really tough patient that I did not fully understand. C. Fairburn generated the single most crushing defeat for another therapy in the literature when 20 weeks of his CBT for eating disorders was more than twice as efficacious as two years of dynamic psychotherapy⁶. D. Freeman is doing some very innovative work with virtual reality in the treatment of paranoid ideation in the schizophrenias⁷. As best I could surmise, the crux of what these colleagues all do is to talk with their patients to get a sense of the idiosyncratic beliefs shaping their problematic behaviors and of what kind of experiences would be required to produce change. The approach they seem to share is to move from open‐ended conversations with their patients to identifying possible mechanisms that they then use to develop intervention strategies that they test first in analogue studies and then in clinical trials⁸. This process is anything but formulistic and it is incredibly successful.

If Hayes and Hoffman can improve on this record for even some, I am all for it and I would not bet against them. As the authors suggest, the “second wave” (cognitive) stood on the shoulders of the “first wave” (behavioral), and it seems right and fitting that the “third wave” should do the same. I wholly agree that we want to follow principles, not protocols, and that the processes that generate and maintain the problems our patients encounter will provide guidance along the way.

I have become enamored with an evolutionary perspective in recent years, and I understand from our conversations that this is true of the authors too. I have come to think of most high‐prevalence low‐heritability psychiatric “disorders” that revolve around negative affect, such as depression and anxiety, as adaptations that evolved to serve a function in our ancestral past⁹. I put the term “disorders” in quotes because these adaptations are neither diseases (there is nothing “broken in the brain”) nor “disorders”; rather, they coordinate an integrated but differentiated array of whole‐body responses to various environmental challenges that increased the reproductive fitness of our ancestors. These evolved adaptations are at least as well treated with psychosocial interventions that facilitate the functions that they evolved to serve as they are with medications, and the former often have an enduring effect that medications simply lack. The low‐prevalence high‐heritability disorders like the schizophrenias or psychotic bipolar disorder likely are “true” diseases in the classic sense of the term and at this time are best treated with medications.

Not all that comes down to us from the past is necessarily wrong, but I do think that any “good idea” tends to be taken too far. When you have a hammer, everything becomes a nail. Variation, selection and retention are the essence of evolution. Mutations produce variation, some of which is selected­ if it outperforms its competition and, if it does, it is then retained in the genes. This process that differentiates and improves the species can do the same for treatment interventions. The authors are to be congratulated for thinking outside the box (introducing variation). If what they produce can outperform the competition, “third wave” processes will thrive and be retained.