The three waves of behavior therapy

The behavioral phase

The first phase of behavior therapy was characterized by its clear scientific orientation and empirical justification. The central endeavor was the development and implementation of learning theory models in therapeutic interventions. The basic learning theories from experimental psychology were applied to behavioral problems and clinical disorders. 

Behavior change occurred both in a direct way, for example, as part of skill training, or by changing the environment, using the Token Economy. 

The approach of this early movement, which was often described as reductionist in character, met resistance early on from other schools of therapy, especially psychoanalysis. The latter was comparatively more hermeneutically oriented in its approach and stood in a humanistic tradition.

The early orientation of behavior therapy had to recognize over time that it could not adequately capture the complexity of clinical disorders. Important progress was made in the analysis of behavior, for example, in demonstrating the relevance of conditioning methods. However, the focus shifted from the effort to change purely observable behavior to the realization that greater importance had to be attached to interpretation and evaluation processes. This realization paved the way for a shift toward the cognitive-behavioral phase of behavior therapy.

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The cognitive-behavioral phase 

With the "cognitive turn" of the 1960s, the theoretical basis of behavior therapy was expanded and the foundation was laid for the following model developments, which are still elementary today. More and more, the preoccupation with the inner world came to the fore. This was a development based on the criticism that the sole focus on simplified learning laws of experimental psychology was not compatible with the importance of cognitive processes in the maintenance of mental disorders.

Both systematic thinking errors and irrational thoughts, as well as dysfunctional schemas, were subsequently used as explanations for the disturbing behavior. Schema concepts and plans were also increasingly used, especially in the treatment of outpatients. Until the 1980s, the cognitive-behavioral approach continued to develop into primarily disorder-specific approaches, including specific models of the development and maintenance of disorders. 

It should be noted that the cognitive behavioral therapy that emerged in these years did not intend to completely discard the original terms and models of the behavioral phase. Rather, interventions were no longer to be limited to the goal of behavioral change, but were to be expanded to include the patient's inner world as a target of change processes. Original methods, such as exposure procedures, continued to be used, but were viewed under new aspects. Thus, exposure was no longer carried out only under the aspect of habituation, but the role of cognitions was also illuminated. The fact that Behavior Therapy and Cognitive Behavior Therapy are nowadays used as synonyms in many places illustrates the importance of the developments of this phase.

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The Third Wave 

Looking back over the past 20 years, there has been a renewed development of behavior therapy. The origin of this was difficulty in treating specific groups of patients. Linehan, for example, observed that her patients with borderline personality disorder responded only to a limited extent to conventional cognitive-behavioral therapy strategies, which is why she included mindfulness and acceptance in particular as important pillars of her therapy - and thus created the basis for Dialectical Behavioral Therapy (DBT). Young, on the other hand, observed that many patients, especially those with chronic depression or personality disorders, did not benefit from structured short-term programs, so he incorporated psychodynamic, hypnotherapeutic, and interpersonal approaches into his treatment. Schema therapy subsequently evolved from this approach. Hayes and colleagues also emphasized the importance of acceptance and working with values, which led to the development of acceptance and commitment therapy (ACT). 

Also, the focus on the attitude of patients toward their cognitions came to the fore, giving rise to Mindfulness-Based Cognitive Therapy and Metacognitive Therapy.

Similar to the transition from the behavioral to the cognitive-behavioral phase, there was an effort at this point not to discard the original cognitive approaches altogether, but to create an extension to the approaches already in practice.

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The Third Wave - a justified designation? 

In general, developments during the 1990s were very heterogeneous, except for the fact that all developments emphasized the relationship between patient and therapist. 

On the one hand, some currents re-emphasized the behavior analytic tradition. In Functional Analytic Psychotherapy (FAP), Dialectical Behavioral Therapy (DBT), Cognitive Behavioral Analysis System of Psychotherapy (CBASP) and Acceptance and Commitment Therapy (ACT) operant processes again play a central role. As a result, voices were raised questioning the fundamental nature of these new developments and thus the justification of the designation as "third wave". 

On the other hand, constructs such as those of acceptance, mindfulness, and spirituality particularly shape Dialectical Behavioral Therapy (DBT), behavior change techniques (BCT), Mindfulness Based Cognitive Therapy (MBCT), and ACT, which is why other behavioral therapists have been confronted with the question of how far the impulses of the "third wave" were still compatible with the basic scientific principles of the original behavior therapy.

Regardless of the conceptual debate, it is important to note that the approaches and forms of therapy that emerged during this period include important innovations that continue to centrally shape the efficiency of Cognitive Behavioral Therapy today. In the following, ACT and CBASP will be presented as examples.

The Acceptance and Commitment Therapy (ACT)

Acceptance and Commitment Therapy (ACT) has a broad empirical base and is widely used as a transdiagnostic approach, for example in the treatment of depression, anxiety disorders, and physical complaints. According to the underlying model of human behavior, the constructs of cognitive fusion and experiential avoidance form central aspects for the development of mental illness. 

In the context of therapy, ACT addresses not so much the cognitions themselves as the ways in which patients respond and relate to them. 

The focus of the treatment is on mindfulness and acceptance techniques, which aim to develop psychological flexibility as well as a lifestyle oriented towards personal values and goals. 

elona therapy integrates elements of ACT into the programs developed for the treatment of anxiety disorders. Patients are introduced to the basics and most important concepts of the therapy form in a comprehensible way, for example, through the pictorial explanation of the Hexaflex model or through courses on the development of one's own values and ideas of acceptance. Various exercises are also provided, for example on the defusion of thoughts.

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Cognitive Behavioral Analysis System (CBASP)

The Cognitive Behavioral Analysis System (CBASP) is the first form of psychotherapy that was developed specifically for chronically depressed patients. The method can be characterized as interdisciplinary, since it integrates behavioral and cognitive as well as interpersonal and psychodynamic approaches in the treatment. The basic assumption is that chronically depressed patients have a developmental blockade that stems from interpersonal experiences. These may be experiences of loss, abuse or neglect. Based on Piaget's stages of development, chronically depressed patients remain in the preoperative stage with regard to their cognitive-emotional state and are thus at the level of children between the ages of four and seven. As a consequence of this developmental deficit, dysfunctional ways of thinking and behaving arise, which in turn lead to the fact that interpersonal situations can be mastered less well. Life stresses and developmental tasks cannot be adequately mastered in the following. McCullough, the founder of this form of psychotherapy, understands CBASP primarily as a learning therapy in which the patient should acquire new ways of thinking and behaving. 

In addition, the goal is to learn new and corrective relationship experiences in order to heal past traumatizing experiences. 

CBASP still has little evidence base, if one compares it to ACT, for example. Nevertheless, current studies clearly recommend the use of CBASP for the treatment of chronically depressed patients with early onset of the disease or relationship experiences. 

elona therapy takes up elements of CBASP, for example by creating a separate section on the topic of "relationships" within the framework of developed courses for the treatment of depression. Within this framework, previous social relationships can be analyzed and explored in relation to the illness, and situation analyses can be prepared by the patients.

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Our conclusion

Looking back at the development of CT, a distinction can be made between a behavioral phase, a cognitive-behavioral phase and a "third wave" of behavior therapy. While the first phase was still very much oriented towards experimental psychology and basic learning laws for the investigation of problematic behavior, the cognitive-behavioral phase expanded this perspective by focusing on the inner world of the patient. In the past 20 years, a "third wave" of behavioral therapy has emerged, in which many new and mostly heterogeneous forms of therapy have emerged. Many of these therapies are still based on the tradition of learning laws, others focus on new constructs, such as mindfulness. 

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ACT as a transdiagnostic approach forms an important evidence-based form of therapy, which has developed in the course of the third wave and is also used in elona therapy for the treatment of anxiety disorders. In addition, elona therapy contains elements of CBASP, which is of great importance as a form of therapy in the treatment of chronically depressed patients and as a method has also grown out of the "third wave" of behavioral therapy.

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