Comparing CBT with Third Wave Therapies 认知行为治疗与（认知行为）第三浪潮疗法之比较
Aaron T. Beck, M.D.
The questions I am most frequently asked at workshops generally revolve around my opinion of the new therapies and how they may fit with cognitive therapy.
我在工作坊里被经常问到的问题大多涉及到我对新疗法以及这些疗法如何适用于认知治疗的看法。
At the outset, I should say the approach of cognitive therapy is not cut in stone. What is relatively invariant, however, is the theory behind the therapy. The theory is essentially incremental as new advances are made in psychology, biology, and related fields. So, for example, there have been many studies linking neurobiological mechanisms with basic cognitive theory. This has led to a more comprehensive neurobiological paradigm for the system of cognitive therapy.
首先，我要说的是，认知疗法的途径不是琢石。然而，相对不变的是治疗背后的理论。这个理论的新进展本质上的渐进，产生于心理学，生物学，以及相关领域。因此，举例来说，现在已经有很多与基本的认知疗法相关的神经生物学机制的研究。指引着认知治疗系统更全面的神经生物学范式。
In making comparisons with the other therapies, particularly the third wave therapies, it is important to make a distinction between a system of psychotherapy (which includes a well validated theoryanda validated therapy derived from the theory) from a set of strategies which do not have solid theoretical backing1.
在与其他疗法、尤其是第三波疗法相比较中，重要的是，去区分系统的治疗（包括各种各样的理论和被这些理论验证的方法）与一整套的、没有坚实理论背景支持的策略。
While the core principles of the cognitive theory have been wellestablished, newer research over the years have expanded the boundaries of the original propositions. This has allowed a very broad extension of the specific formulation of numerous disorders, as well as new understandings of human nature, problems with everyday life, and problems and difficulties between people and groups.
当认知疗法的核心原则已经很好的建立后，新的研究多年来不断的扩展来了最初命题的边界。这使得对许多特殊情况下的失调、对人性的理解、日常生活中的问题、以及人与团体之间的问题与困难，有了一个非常广泛的延伸。
The underpinning of a successful theory not only facilitates the development of new strategies, but insuresdurability. A basic exposition of the theory’s cognitive structures allows for the development of techniques to modify these structures in a durable way.成功理论的基础支柱不仅有利于新策略的发展，同时要确保其持久性。理论认知结构的基本阐述，允许技术的发展以持久的方式来修改这些结构。
Because the original core theory and its expansion provide a broad framework for human understanding, the cognitive model is easily converted into specific minitheories applicable to a wide variety of disorders and human problems. Furthermore, these minitheories are easily adapted to specific formulations of a specific case.由于原有的核心理论及其扩展为人们的理解提供了一个宽广的框架。认知模型很容易转化成特殊的微小理论，适用于广泛而多样的障碍和人的问题。与此同时，这些小理论很容易地适用于一个特定的情况下的具体案例。
A useful way of conceptualizing individual’s reactions to events and particularly to psychopathology is the following:个体对事件的反应、尤其是精神病理学的概念化之有效方法如下：
Cognitive processing consists of two systems. The first system is reflective, automatic, and relatively crude. It breaks events into evaluative categories (good, bad, threatening, loss, gain) and is absolute. This system is also linked to automatic memory. Since it responds so rapidly we can call it thereflexive system.认知处理由两个系统组成。第一个系统是反射的，自动的，相对粗糙的。它将事件打碎成评价的类别（好的，坏的，恐吓性的，获得，失去），并且是绝对的。该系统还与自动化记忆相关。由于它的反应如此之快，我们称其为反射系统。
Cognitive restructuring (as in CT) also includes distancing from the negative cognitions but, in addition, has a powerful corrective impact on the negative schemas, as well as reinforcing rational processes.
A second system, which we can call the reflective system, is deliberate and utilized to correct the errors or inaccuracies in the first system, as well as to solve problems.我们将第二个系统称之为反省系统，
There already are suggestions of neurobiological correlates of these systems. Thus, thereflexive systemconsists of excitation of the pathways leading from the thalamus to the amygdala, hypothalamus, and the anterior cingulated prefrontal lobe. In depression, the prefrontal lobes are deactivated where as the rest of the circuitry is activated. The trick is to focus on mechanisms of action. Where does each of the therapies actually operate? The reflexive system is often referred to as the “automatic processing system” and the reflective system as “controlled processing.”
There are a variety of reasons why the products from the reflexive system are often incorrect, and at times irrational. When the second system is activated, however, it can rapidly modify the contents of the products of the first system.
Therapists can feel comfortable with the applications of the theory and the strategies utilized to implement the theory because both the theory and the expansions and the therapies derived from them have been validated.2
Acceptance and commitment therapy (ACT), dialectical behavior therapy (DBT), mindfulness, and therapy based on relationship variables (“common factors”) have a beginning track record, but the theoretical basis is often uncertain. The relationship of theory to the therapy is weak, and the theory lacks evidence.
接受与承诺疗法，辩证行为疗法，正念以及基于关系变量（共同因素）的疗法有着早期的记录，但是理论的基础时常不确定。理论与治疗之间的联系较弱，理论也确少证据。
The literature shows that mindfulness techniques produce a detachment from ongoing preoccupations (decentering) and increased perspective taking. In theory, this should activate the rational system (centered in the prefrontal lobe) and consequently attenuate the negative automatic processing.
The acceptance component aspect of ACT and DBT acts in a somewhat similar way. Dysfunctional thoughts are accepted simply as thoughts —— which enables the patient to acquire some distance from them. Distancing, objectivity, and perspective taking are related to the increased activity of the rational system.
Cognitive restructuring (as in CT) also includes distancing from the negative cognitions but, in addition, has a powerful corrective impact on the negative schemas, as well as reinforcing rational processes.
Finally, the relationship factors approach includes the triad of unconditional acceptance, genuine warmth, and accurate empathy. All of these can serve to improve the patients self esteem and negate and undermine the negative processing.
Conclusion
1. What is the comparative efficacy of CT and the third wave therapies? A simplistic answer is that the comparative randomized control studies have not yet been carried out sufficiently to come to a conclusion.
2. It is possible that a certain equivalence between the therapies may occur in a welldesigned study. However, the equivalence at the end of treatment may be misleading. An essential feature of the efficacy of psychotherapy is its durability over an extended period of time, and after the comparison therapies have been discontinued. The durability is measured by maintenance or improvement in the outcome and a lack of relapse. Some studies, for example, have shown an equivalence at the end of treatment but a substantial difference in longer term follow up (for example, a comparison of cognitive therapy and befriending with patients with schizophrenia).
3. A newer approach to the robustness of a therapy is based on the complexity and richness of the underlying theory. A robust theory, for example, can generate new therapies or can draw on existing therapies that are consistent with it.
4. Cognitive therapy has relied on a number of powerful vehicles such as structured interview, feedback, action plan, and cognitive restructuring to implement cognitive change (which is the important mechanism of change derived from theory). However, the same theory can be utilized to generate a variety of other techniques, particularly when the standard techniques are not appropriate for a given patient or problem.
5. An essential characteristic criterion of a successful theory is that theoretical constructs have been validated. The underlying theory of cognitive therapy has been subjected to hundreds of studies, almost all of which have been supportive of the theoretical hypothesis.2
6. As compared to the third wave therapies, cognitive therapy has a much richer theoretical foundation. Cognitive therapy has shown such durability in many clinical comparisons with antidepressant drugs. This has not yet been demonstrated in any third wave therapies.
7. While cognitive therapy has relied on standardized therapeutic strategies, for the most part, it is not bound to these strategies and can (and does) adopt other therapeutic strategies when the standard ones are not considered appropriate.
8. The broad scientifically validated theories underlying cognitive therapy provide for a broad spectrum therapy that can be applied to the broad spectrum of psychiatric disorders for individuals seeking treatment.
9. So far as the third wave therapies are integrated into the broad theoretical and therapeutic system of CT, they can be utilized in addition to, or in place of, the standard approach.
References
1 Beck, A. T. (1976) Cognitive therapy and the emotional disorders. Oxford, England: International Universities Press.
2 Clark, D. A., Aaron T. B., and Alford, B., A., (1999) Scientific foundations of cognitive theory and therapy of depression. New York, John Wiley and Sons.
3 Disner, S. G., Beevers, C. G., Haigh, E. A. P., Beck, A. T. (2011). Neural mechanisms of the cognitive model of depression. Nature Reviews Neuroscience, 12, 467-477.
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