Enough Already with Syndromes

The future of evidence-based behavior change

Posted Sep 25, 2017

When Acceptance and Commitment Therapy (ACT) first appeared on the scene in a big way, mainstream Cognitive Behavior Therapy (CBT) was not exactly thrilled. In 2004 I’d declared the arrival of the "third-wave" of acceptance and mindfulness based methods in CBT and evidence-based intervention generally. In 2005 Get Out of You Mind and Into Your Life appeared and became the first general ACT self-help book. In 2006 a 5-page story in Time Magazine about that book rocketed it up to #20 overall (beating Harry Potter for one glorious week!).

Unfortunately, the late John Cloud (the Time reporter and a sweet man who later became my friend) cast ACT as a kind of rebel threat to CBT. Ouch.

Stefan Hofmann protested loudly and forcefully in writing, and so I did what any good ACT person would do: I invited him to our major convention (the
"World Conference" of the Association for Contextual Behavioral Science). He came, somewhat leary, and we did what one would expect – we argued loudly and forcefully – and overall just had a great time. I could not get him on stage at the ACBS follies -- a self-deprecating comedic romp that is a tradition at WorldCon -- but he laughed more loudly than anyone when the whole audience repeated a take off of the “Horton Hears a Who” poem about ACT and CBT, shouting “we are here, we are here, we are here, we are here”.

Over the years our arguments became discussions and our discussions became collaborations. It turned out once again that what I’ve always believed was proven true: in science, bridges are stronger than walls.

Fast forward to today. Now good friends as well as colleagues, Stefan and I think we see a way forward for evidence-based psychotherapy.

For nearly 50 years intervention science has pursued the dream of establishing evidence-based therapy by testing protocols for syndromes in randomized trials. That era is ending.

Why? After 40 years of flogging this particular dead horse it is clear that syndromes (lists of signs and symptoms gathered into categories) will never tell us what we really want to know: why are people suffering so, and what can we do about it?

The National Institute on Mental Health has turned away from syndromes as an avenue of progress (though the mainstream public does not seem yet to have realized that the money flow to that enterprise has stopped). Models that cut across syndromal categoreis, like ACT, are getting stronger almost by the day. Projects such as the NIMH’s Research Domain Criteria (RDoC) are focusing attention on underlying mechanisms.

CBT prospered in the era of protocols for syndromes. Effective and widely disseminated, it nevertheless struggled in several areas -- processes of change, theoretical development, clarity about philosophical assumptions. Overall it seemed that the core of CBT was beyond question until the arrival of the “3rd wave” shook the tradition to its foundation. New methods and new assumptions challenged the status quo. Now 13 years after its announced arrival, it is possible to look back and see it in a different light. 

Superficially, it appeared as though the change was all about acceptance, or mindfulness, or values. It was far deeper than that. 

Stefan and I have just written an article together that just came out in the journal World Psychiatry. We concludes that the most important thing about the “3rd wave” was that it anticipated the transition to a more process-based model of evidence-base care in which care providers would focus on processes of change that lead to good outcomes, instead of lists of signs and symptoms.

It is a short piece which the journal has made available free for downloading. If you want to see a pithy version of what we think the future of evidence-base therapy will look like and why, you can get the article here: 



Hayes, S. C. & Hofmann, S. G. (1917). The third wave of cognitive behavioral therapy and the rise of process-based care. World Psychiatry, 16, 245–246. DOI: 10.1002/wps.20442