اهمیت نظریه در رفتار درمانی شناختی: چشم انداز علوم رفتاری متنی

For the past 30 years, generations of scholars of cognitive behavior therapy (CBT) have expressed concern that clinical practice has abandoned the close links with theory that characterized the earliest days of the field. There is also a widespread assumption that a greater working knowledge of theory will lead to better clinical outcomes, although there is currently very little hard evidence to support this claim. We suggest that the rise of so-called “third generation” models of CBT over the past decade, along with the dissemination of statistical innovations among psychotherapy researchers, have given new life to this old issue. We argue that theory likely does matter to clinical outcomes, and we outline the future research that would be needed to address this conjecture.

For years, scholars of the family of psychotherapy approaches known under the broad umbrella of cognitive behavior therapy (CBT) have been calling for an increased focus on the theories that underlie applied technologies. The common theme of these appeals is that there has been a gradual erosion of the strong connection between theory and technique that characterized the field’s early days, and that a renewed focus on such links will lead to more rapid and reliable advances in our understanding, development, testing, implementation, and dissemination of CBT approaches. In his 1984 presidential address of the Association for Advancement of Behavior Therapy (now the Association for Behavioral and Cognitive Therapies; ABCT), Alan Ross lamented that “a reading of the current literature on behavior therapy suggests that the field is at risk of losing its momentum in a preoccupation with technological refinements at the expense of theoretical developments” (Ross, 1985, p. 195). Wilson and Franks (1982) similarly decried the rapid proliferation of clinical techniques decoupled from theory, suggesting that this trend could ultimately sow the seeds of the field’s demise. More recently, Beck (2012) noted that ". . . 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" (p. 6). David and Montgomery (2011) proposed a new framework for defining evidence-based psychological practice that prioritizes the level of empirical support of the theory supporting a treatment. Recommendations that clinicians should develop better working knowledge of the theories underlying CBTs often are presented during discussions of how to maximize treatment outcomes, prevent treatment failures, and ameliorate treatment resistance in complex cases (Foa and Emmelkamp, 1983, McKay et al., 2010 and Whisman, 2008). An interorganizational task force led by the ABCT recently issued a report on doctoral training in cognitive behavioral psychology in which training in theory and even the philosophy of science underlying CBTs was emphasized (Klepac et al., 2012). The call for greater emphasis on theory within CBT therefore spans the generations. In fact, if one were to mask the author and date, it would be hard to distinguish writings on this subject made by contemporary authors from those written over 30 years ago. There appears to exist a widespread assumption among many clinicians and researchers alike that better knowledge of theory will bear fruit in terms of improved clinical outcomes across a number of contexts. Although this notion has considerable face validity, there is a paucity of research that has directly evaluated it. Historically, the desire for empirically supported treatments led to testing psychotherapies in controlled clinical trials to determine their efficacy, a procedure borrowed from other medical treatments. For example, the seminal study known as the National Institute of Mental Health's Treatment of Depression Collaborative Research Program (Elkin et al., 1995) randomized patients with major depression to cognitive therapy, interpersonal psychotherapy, or antidepressant medication, and ushered in a new era of evaluating psychotherapies in large-scale and methodologically rigorous clinical trials. CBTs, given their empirical basis, inherent structure, and time-limited nature, were particularly well-suited for testing in clinical trials. As a result, CBTs became highly manualized in an effort to ensure treatment fidelity, an important component of the internal validity of such trials (Addis & Krasnow, 2000). Originally CBTs were more principle-driven and theory-dependent in the way that they were conceptualized and implemented (e.g., Goldfried & Davison, 1994). With the growth of clinical trials during the 1970s and 80s, however, treatment manuals began to focus more on how to implement specific CBT techniques and strategies and less on interventions derived from case conceptualization based on the ideographic assessment of the patient guided by an underlying theory. We are unaware of data directly comparing the level of theoretical knowledge of early practitioners of behavior therapy relative to modern CBT clinicians. Nevertheless, even a casual comparison of the field’s early books and journals targeting clinicians relative to later works reveals a stark contrast in the degree of emphasis on theory. As the evidence base for CBTs expanded due to the rapid accumulation of supportive efficacy research, the problem of how best to implement and disseminate the treatments emerged as a pressing problem (Addis, 2006). Although novel psychotherapies typically begin in complex and sophisticated forms because they are created by experienced researchers and clinicians, disseminating them to community practitioners exerts pressure to simplify them as much as possible. It is easier to train nonexpert therapists to implement a set of standard techniques than it is to train them to comprehend an underlying theory. Once standard techniques are mastered, clinicians well versed in theory can potentially apply their knowledge to unique cases in order to deduce tailored interventions. The picture is complicated further because there is no single CBT model, nor single theory underlying it. CBT is a broad umbrella term that encompasses a range of distinct therapy models (Herbert & Forman, 2011). These models share certain features, while also having distinct characteristics. The theories underlying these approaches likewise share certain commonalities (e.g., traditional respondent and operant conditioning principles), while also positing unique features. Moreover, key theoretical issues, such as the best way to understand the role of cognitive processes in treatment, are currently the subject of intense professional debate (Hofmann, 2008, Longmore and Worrell, 2007 and Worrell and Longmore, 2008), and have undergone considerable changes over the years (Beck, 2005). We believe that two developments over the past decade have added a new twist to the long-standing question about the role of theory in guiding psychotherapy. First, the question has been reinvigorated by the rise of the so-called “third wave” (also known as “third generation”) models of CBT. These newer CBT approaches such as Mindfulness-Based Cognitive Therapy (Segal, Williams, & Teasdale, 2002), Dialectical Behavior Therapy (Linehan, 1993), and especially Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 2011) eschew a simplistic focus on specific techniques and strategies in favor of increased attention to the putative principles underlying behavior change, which are in turn linked with basic psychological theories (Ablon et al., 2006, Hayes, 2004 and Rosen and Davison, 2003). Second, psychotherapy treatment researchers have increasingly focused on therapy processes using component analysis studies (Borkovec and Sibrava, 2005 and Lohr et al., 2003) and the identification of treatment-related mediators and moderators (Kraemer, Wilson, Fairburn, & Agras, 2002). These two developments have had synergistic effects, further stimulating discussion of the role of theory in CBTs. For example, calls by proponents of third-generation approaches to focus on psychotherapy processes, rather than merely techniques, has accelerated research on the mechanisms of action in CBTs more generally. Simultaneously, more accessible and advanced statistical procedures have made it easier for researchers to investigate mechanisms of change, and have stimulated therapy innovators to evaluate the proposed theories underlying their approaches. Although the argument that understanding theory will improve clinical outcomes has been a perennial theme in the field, innovations associated with the development of third-generation models of CBT, along with the development of new statistical tools, have brought this issue back into the forefront of discussion. We should not lose sight of the fact that proponents of the utility of theory are often themselves theoreticians and may thus overestimate the importance of theory. The extent to which improving clinicians' theoretical knowledge does, in fact, result in improved clinical outcomes is ultimately an empirical question. The best approach to evaluating this supposition is itself complicated and will require clarification of a number of related issues. First and foremost, are there compelling reasons to hypothesize that knowledge of theory will, in fact, improve outcomes? Second, what evidence, if any, currently supports the notion that gaining a better theoretical understanding of a psychotherapeutic approach enhances outcomes over and above mere technical knowledge of the approach? Third, even if theoretical knowledge is found to accrue incremental benefits, does it pass a cost-benefit test? Fourth, if such efforts can indeed be demonstrated to be cost effective, how much theoretical knowledge and training is needed to improve outcomes? Fifth, which theory or theories should be prioritized? Presumably, some theories have greater breadth, depth, precision, explanatory power, and incremental efficacy than others, making them more useful guides. Sixth, to what degree is it necessary simply to understand theory in abstract terms versus being able to apply it to individual cases? And seventh, and perhaps most fundamentally, what exactly do we mean by the term “theory”? We will briefly explore these and related questions regarding the role of theory, using ACT in particular as a case in point. 1

Scholars of psychotherapy, and of CBTs in particular, have repeatedly called over the past three decades for renewed interest in theory, and there are signs that the field is beginning to heed such calls. This renewed appreciation of the role of theory is driven by the confluence of a number of factors, including the growth of third-generation models of CBT that tend to emphasize linking technique to theory, and the development of refined statistical methods to study psychotherapy processes. Although the ideal role of theoretical knowledge in clinical practice is ultimately an empirical question, there are good reasons to hypothesize that a working knowledge of theory may lead to enhanced outcomes. Evaluating these questions will require a multifaceted research program, which will in turn depend on first addressing a number of conceptual issues regarding the nature of theories to be examined. The importance of examining the role of theory in clinical practice is underscored by recent initiatives to disseminate CBTs widely to front-line practitioners. Beginning in 2006 the U.K. governments have been implementing the Improving Access to Psychological Therapies program (Department of Health, 2011), which has committed hundreds of millions of dollars to training thousands of therapists to provide CBT to over 600,000 people with disorders such as depression and anxiety. In the U.S., the VA is implementing a similar initiative to train clinicians in CBT to improve access to effective treatment among military veterans (Ruzek, Karlin, & Zeiss, in press). Taking full advantage of these efforts will require not only further theoretical developments, but also a better understanding of the role of theory in clinical practice.