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COMMENTARY United We Stand: Emphasizing Commonalities Across Cognitive-Behavioral Therapies Douglas S. Mennin Hunter College and the Graduate Center, City University of New York Kristen K. Ellard Boston University David M. Fresco Kent State University James J. Gross Stanford University Cognitive behavioral therapy (CBT) has a rich history of alleviating the suffering associated with mental disorders. Recently, there have been exciting new developments, including multicomponent approaches, incorporated alterna- tive therapies (e.g., meditation), targeted and cost-effective technologies, and integrated biological and behavioral frameworks. These field-wide changes have led some to emphasize the differences among variants of CBT. Here, we draw attention to commonalities across cognitive-behavioral therapies, including shared goals, change principles, and therapeutic processes. Specifically, we offer a framework for examining common CBT characteristics that emphasizes behavioral adaptation as a unifying goal and three core change principles, namely (a) context engagement to promote adaptive imagining and enacting of new experiences; (b) attention change to promote adaptive sustaining, shifting, and broadening of attention; and (c) cognitive change to promote adaptive perspective taking on events so as to alter verbal meanings. Further, we argue that specific intervention components, including behavioral exposure/activation, at- tention training, acceptance/tolerance, decentering/defusion, and cognitive reframing, may be emphasized to a greater or lesser degree by different treatment packages but are still fundamentally common therapeutic processes that are present across approaches and are best understood by their relation- ships to these core CBT change principles. We conclude by arguing for shared methodological and design frameworks for investigating unique and common characteristics to advance a unified and strong voice for CBT in a widening, increasingly multimodal and interdisciplinary, intervention science. Keywords: cognitive behavioral therapy; CBT; common principles; intervention science; integration COGNITIVE-BEHAVIORAL THERAPIES (CBTs) constitute a family of clinical interventions designed to produce behavior change. However, CBT approaches are themselves subject to growth and change. Moments of seemingly paradigmatic change within CBT reveal an age-old tension between conserving what is known to work well and pushing to expand the field beyond what is already known to be true. An early instance of this tension emerged during the cognitive revolutionof the 1970s, during which Behavior Therapy 44 (2013) 234 248 www.elsevier.com/locate/bt Address correspondence to Douglas S. Mennin, Ph.D., Department of Psychology, Hunter College, 695 Park Avenue, HN611; New York, NY 10065; e-mail: [email protected]. 0005-7894/44/234248/$1.00/0 © 2013 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.

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Behavior Therapy 44 (2013) 234–248www.elsevier.com/locate/bt

COMMENTARY

United We Stand: Emphasizing Commonalities AcrossCognitive-Behavioral Therapies

Douglas S. MenninHunter College and the Graduate Center, City University of New York

Kristen K. EllardBoston University

David M. FrescoKent State University

James J. GrossStanford University

Cognitive behavioral therapy (CBT) has a rich history ofalleviating the suffering associated with mental disorders.Recently, there have been exciting new developments,including multicomponent approaches, incorporated alterna-tive therapies (e.g., meditation), targeted and cost-effectivetechnologies, and integrated biological and behavioralframeworks. These field-wide changes have led some toemphasize the differences among variants of CBT. Here, wedraw attention to commonalities across cognitive-behavioraltherapies, including shared goals, change principles, andtherapeutic processes. Specifically, we offer a framework forexamining common CBT characteristics that emphasizesbehavioral adaptation as a unifying goal and three corechange principles, namely (a) context engagement to promoteadaptive imagining and enacting of new experiences;(b) attention change to promote adaptive sustaining, shifting,and broadening of attention; and (c) cognitive change topromote adaptive perspective taking on events so as to alterverbal meanings. Further, we argue that specific intervention

Address correspondence to Douglas S. Mennin, Ph.D., Departmentof Psychology, Hunter College, 695 Park Avenue, HN611; NewYork,NY 10065; e-mail: [email protected]/44/234–248/$1.00/0© 2013 Association for Behavioral and Cognitive Therapies. Published byElsevier Ltd. All rights reserved.

components, including behavioral exposure/activation, at-tention training, acceptance/tolerance, decentering/defusion,and cognitive reframing, may be emphasized to a greater orlesser degree by different treatment packages but are stillfundamentally common therapeutic processes that are presentacross approaches and are best understood by their relation-ships to these core CBT change principles. We conclude byarguing for sharedmethodological and design frameworks forinvestigating unique and common characteristics to advance aunified and strong voice for CBT in a widening, increasinglymultimodal and interdisciplinary, intervention science.

Keywords: cognitive behavioral therapy; CBT; common principles;intervention science; integration

COGNITIVE-BEHAVIORAL THERAPIES (CBTs) constitute afamily of clinical interventions designed to producebehavior change. However, CBT approaches arethemselves subject to growth and change. Momentsof seemingly paradigmatic change within CBTreveal an age-old tension between conservingwhat is known to work well and pushing to expandthe field beyond what is already known to be true.An early instance of this tension emerged during the“cognitive revolution” of the 1970s, during which

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period cognitive frameworks began to increase inpopularity. Radical behavior therapists at the timerightfully criticized this movement for its lack ofempirical base and tendency to “speak past thedata” (Goldfried, 2010). However, the cognitiveperspective eventually became central to the char-acter of CBT, establishing an empirical base interms of the role of cognitive factors such asattention, memory, and judgment in assessmentand intervention (although the role of disputationas a necessary technique remains a point of debate;Jacobson, Martell, & Dimidjian, 2001).Today we are once again faced with identity issues

and challenges as to how best to grow, refine, andpossibly redefine what it means to be a cognitive-behavioral theorist, researcher, and therapist. Animportant voice in the current expansion of CBTscomes from Acceptance and Commitment Therapy(ACT; S. Hayes, Strosahl,&Wilson, 1999; S. Hayes,Levin, Plumb-Vilardaga, Villatte, & Pistorello,2013–this issue), Dialectical Behavior Therapy(DBT; Linehan, 1993),Mindfulness-BasedCognitiveTherapy (MBCT; Segal, Williams, & Teasdale,2002), Behavioral Activation (BA; Martell, Addis,& Jacobson, 2001), the Unified Protocol (UP;Barlow et al., 2011), Motivational Interviewing(MI; Miller & Rollnick, 1991), and Compassion-Focused Therapy (CFT; Gilbert, 2009), to name justa few of the many promising approaches that arestretching the boundaries of the CBT framework.Other approaches have combined traditional(“tCBTs”) and recent (“rCBTs”) approaches eitherin additive (Interpersonal Emotional Processing,Newman et al., 2011; MBCT; Segal et al., 2002) orintegrative designs (STAIR-PE; Cloitre, Koenen,Cohen, & Han, 2002; Acceptance-Based BehavioralTherapy; ABBT; Roemer & Orsillo, 2009; Exposur-e-Based Cognitive Therapy; EBCT; A. Hayes et al.,2007; Emotion Regulation Therapy; ERT; Mennin& Fresco, 2009).Spirited debates about the similarities and differ-

ences between tCBTs and rCBTs (Arch & Craske,2008; Craske et al., 2008; Herbert & Forman,2013–this issue; Hofmann & Asmundson, 2008)—including the present issue of Behavior Therapy—have focused on whether newer approaches such asACT have empirical support for their efficacy (“theydon’t” vs. “they’re developing it”; Gaudiano, 2009;Öst, 2008); and whether it is novel (“they’re old hat”vs. “they’re something new”; Hofmann & Asmund-son; S. Hayes et al., 2013–this issue). In regards to thefirst issue, as S. Hayes and colleagues point out,tCBTs have been around longer and thus haveachieved a significant empirical base (e.g., Butler,Chapman, Forman, & Beck, 2006; Tolin, 2010).Despite methodological weaknesses in some studies

(Öst, 2008), initial evidence indicates that rCBTs areefficacious (S. Hayes et al.). Given more rigorousinvestigations, time will likely establish a strongempirical base of efficacy for rCBTs including ACT.The latter issue, concerningwhether thismovement isnovel, is one that concentrates the debate on what isdifferent about these approaches. However, shiningthe light heremay inordinately focus the discourse onthe fringes, thereby picking apart smaller differencesat the boundaries while ignoring the substantialoverlap and synergy of these approaches.Both S. Hayes and colleagues (2013–this issue) and

Hofmann Asmundson, & Beck (2013–this issue)accentuate the distinctive philosophical and theoret-ical foundations of their approaches in their respec-tive target articles. Correspondingly, numerousinvestigations have examined the comparative utilityof rCBTs versus tCBTs. Trials testing these ap-proaches typically involve comparison of the newapproachwith an established tCBT for that condition(e.g., substance dependence) or contextual problem(e.g., marital difficulties). This comparative efficacyRCT design is the gold standard for determining if atreatment comprised of new components is effica-cious. The comparison and demonstrated equivalenceor superiority to established treatments is considered acrucial step in determining the empirical basis of atreatment. Indeed, the major systems for determiningefficacy of psychosocial interventions (e.g., APA/Division 12 guidelines: http://www.div12.org/PsychologicalTreatments/index.html; NICE’s guide-lines; http://www.nice.org.uk) utilize this gold stan-dard for determining if a new approach withdiscernable features can offer a distinctive approachvia the ability to provide greater or more pervasiveefficacy, encompassing refractory cases that have beendifficult to treat with more established interventions.Drawbacks to this “horse race” approach have

been noted throughout numerous articles (Borkovec& Castonguay, 1998; Lohr, 2011). In particular,S. Hayes et al. (2013–this issue) point out that thisapproach is quite slow. In addition, these studiesmaybe unable to find distinctions that are anythinggreater than incremental given the inherent similar-ities in compared CBTs (as opposed to comparingCBT to another approach). Given this heterogeneitywithin the CBTs, a predominant focus on compar-ative efficacy may be ill advised given the likelihoodof high overlap among these approaches and, hence,any direct comparison is likely to be costly, timeconsuming, and incremental in the information itprovides about matching key components to ame-liorating the suffering of themost refractory patients.We agree that delineating and empirically eval-

uating core components of different approaches isvital. There clearly are “proprietary” intervention

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components inherent to each treatment package orapproach. However, much of what the CBT modelshave declared as unique may actually reflectcommon intervention characteristics, includingshared goals, principles, and processes. Castonguay(2011) posits that these distinctions often reflect“faux-uniqueness,” leading investigators to focuson small distinctions rather than large commonal-ities. In that spirit, we argue that there is a base ofcommon characteristics that can harmonize tCBTand rCBT. By delineating these common character-istics, a collective language and investigativestrategy can be generated that may help increaseprecision and efficiency in advancing our under-standing and treatment of refractory psychopathol-ogies.Our goal is to emphasize the importance of CBT

within a broader intervention science that is increas-ingly multimodal as well as interdisciplinary. Specif-ically, interventions have become progressively moreheterogeneous as evidenced by a greater variety ofmulticomponential therapy packages, the integrationof alternative therapies (e.g., meditation; Kabat-Zinn,1994), and the development of targeted lab-basedinterventions (e.g., attention modification program;[AMP]; Amir, Beard, Burns, & Bomyea, 2009).In addition, psychosocial interventions are morecommonly targeting the interplay of both behavioraland biological components (Zinbarg, Mashal, Black,& Flückiger, 2010). Given this wider investigativefield, it is crucial that proponents of CBT clearlyemphasize the value of their core offerings (i.e., theshared components of CBT) rather than engage inself-destructive internecine wrangling.Echoing the calls of others (e.g., David &

Montgomery 2011; Hofmann Asmundson, & Beck,2013–this issue; Lohr, 2011), we recommend a moveaway from a stringent focus on comparative efficacybetween similar approaches and, rather, emphasizethe delineation of common characteristics of all CBTs(encompassing both tCBTs and rCBTs), includingcommon goals, change principles, and therapeuticprocesses. However, a shift from predominantly acomparative efficacy focus to one that emphasizescharacteristics of changemeans it will be important toclearly define what these characteristics are and howthey relate to the current debate about similarities anddifferences between tCBTs and rCBTs such as ACT.In the remainder of the paper, we argue that CBTsshare a common framework for intervention, includ-ing a common goal of behavioral adaptation andcorresponding change principles of context engage-ment, attention change, and cognitive change thatpromote this goal. Further, we argue that specificintervention components such as behavioral expo-sure, behavioral activation, attention training,

acceptance/tolerance, decentering/defusion, and cog-nitive reframing may be emphasized to a greater orlesser degree by different treatment packages but theyare still fundamentally common therapeutic processesthat are present across approaches and are bestunderstood by their relationships to these core CBTchange principles.

A Model of Commonalities Across CBTsbehavioral adaptation as the unifying goalof cbt

Reading the target articles of this series, one mightthink that different CBTs have different goals. Forexample, ACT emphasizes flexibility as the para-mount objective in their hexaflex model of change(S. Hayes et al., 2013–this issue); tCBTs privilege therestoration of overall functioning (via symptomreduction). But, both flexibility and functionalityreflect an overarching purpose to help individualsoptimize their adaptation to circumstances that arisein their lives. By behavioral adaptation, we refer tothe process by which organisms become better suitedto prospering in their habitats (Dobzhansky, 1970).Humans have learned a variety of behaviors thathave enabled us to populate large swathes of ourplanet, forage far and wide, and provide protectionfrom environmental conditions while gainingadvantages over other species that would otherwisecompete for nourishment and possibly prey on us.Making appropriate behavioral responses may be

the difference between life and death and betweenlove and loss. Examples of such opportunities forsuccess are being maximally industrious for survival,successfully finding partners for co-habitation, andeffectively communicating and building cooperationin group and culture systems (Keltner & Haidt,1999). Individuals suffering fromemotional disordersmay demonstrate habitually inflexible and dysfunc-tional responses in these situations and, subsequently,a primary goal of CBTs is to direct interventionstowards cultivating more behaviorally adaptive re-sponses in order to survive and thrive in theseimportant life domains. Whatever their differences,CBTs work to promote behavioral adaptation byassigning meaning to exteroceptive and interoceptivecues and encouraging the use of this information totake effective action.

cbt principles and processes that promotebehavioral adaptation

In addition to behavioral adaptation, CBTs sharecommon change principleswith respect towhat needsto be changed for a given treatment goal to be realized(see Goldfried & Davila, 2005; Rosen & Davison,2003). Specifically, these core change principlesrepresent the roadmap for how to best promote

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behavioral adaptation. Although there are likely otherprinciples within the family of CBTs, three core CBTprinciples are: (a) context engagement to promoteadaptive imagining and enacting of new experiencesto counteract old and well-worn patterns of mal-adaptive associations and reinforcement; (b) attentionchange to promote adaptive sustaining, shifting, andbroadening of attention to changing contexts; and(c) cognitive change to promote adaptive perspectivetaking on an event so as to alter verbal meanings andtheir emotional significance. These change principlesrepresented in a myriad of CBTs (as examples, seeCloitre et al., 2002; Craske & Barlow, 2008) alsoreflect the basic science of emotion regulation. Gross(2002) has demonstrated that emotional respondingcan be influenced along a temporal continuum. Onecan impact an emotional event via early selection ormodification of a situation (the primary target ofprocesses that promote context engagement), earlystages of emotional processing (the primary target ofprocesses that promote attention change), or at laterstages of emotional processing (the primary target ofprocesses that promote cognitive change).It is important to note that emotional responding,

according to Gross’s (2002) model, can also beinfluenced by attempting to impact the quality of aresponse (i.e., response modulation). Congruently,many tCBTs target a change in the quality ofexisting emotional responses to achieve symptomreduction and distress relief. For instance, progres-sive muscle relaxation has traditionally been used toreduce tension associated with apprehensive anxi-ety. Indeed, these approaches have establishedconsiderable efficacy (e.g., Borkovec, Newman,Pincus, & Lytle, 2002) and, for a number ofpopulations such as children and cognitivelychallenged individuals, they may be a useful toolto help ameliorate suffering in individuals who lackthe capacity to fully engage attention or cognitivechange. However, approaches such as ACT havenoted the difficulties associated with attempts tocontrol a currently experienced emotion and havebased a good deal of their approach on the notionthat doing this is detrimental to change in the longrun for the client (see Hayes et al., 2013–this issue).Thus, we have opted not to address responsemodulation as a change principle as it is notuniversally encouraged by all CBT approachesand, thus, is not considered a common principle.Numerous therapeutic processes common to

the family of CBTs can be seen as differentiallypromoting these change principles. Specifically,therapeutic processes of behavioral exposure(i.e., the encouraging of physical or imaginalmovement towards threatening contexts) and behav-ioral activation (i.e., the encouraging of physical or

imaginal movement towards rewarding contexts)can be seen as primarily reflecting the principle ofcontext engagement. Further, attention training(i.e., encouraging the direct manipulation of atten-tion in specific directions) and acceptance/tolerance(i.e., encouraging the allowance and unfolding offeeling states) can be seen as primarily reflectingthe principle of attention change. Finally, cognitivechange is a target of cognitive reframing interven-tions (i.e., encouraging the changing of one’sevaluation of an event to alter its emotionalsignificance) but can also be seen as a principle thatencompasses meta-cognitive distancing processesincluding decentering/defusion (i.e., encouragingidentification, observation, and generation of psy-chological perspective from inner experiences), aswell. Some treatments may be more likely toemphasize attention change principles (e.g., mind-fulness-based treatments) and some might bemore likely to emphasize cognitive change principles(e.g., cognitive therapy), but no existing approachcan claim to focus fully on any one process orprinciple. More likely, current CBT approachestarget multiple entry points in the emotional cascadeand are thus likely to reflect and align with each ofthese principles, albeit with varying degrees ofengagement of different specific processes.Figure 1 provides a conceptual model of behav-

ioral adaptation reflected in common principles andcorresponding therapeutic processes. This list ofprinciples and processes is not exhaustive. None-theless, we argue that the therapeutic processesconsidered in this paper largely target the hypoth-esized change principles comprised in the broaderfamily of CBTs. This relationship between thera-peutic processes and targeted change principles isdenoted in Figure 1 by solid lines. However, currenttherapeutic processes are blunt instruments thatmay also collaterally impact other principles(e.g., behavioral activationmight increase attentionalabilities in addition to promoting context engage-ment). It remains a challenge to the field to focalizeinterventions such that they are able to increasinglyreflect precision in targeting specific change principlesof interest. The ability to develop increasingly precisetherapeutic processes reflective of clear changeprinciples will be essential for the field to offer whatare the key ingredients of CBTs that contribute best toefficacy and then to isolate these ingredients such thatour treatments aremost parsimonious (Cougle, 2012;see below) yet maximally effective. However, giventhe current state of heterogeneous relationshipsbetween current therapeutic processes and changeprinciples, Figure 1 also displays dotted lines connect-ing therapeutic processes with nontargeted changeprinciples in recognition that these processes may not

FIGURE 1 Common Cognitive Behavioral Characteristics of Change (Goal, Change Principles, Therapeutic Processes). Note.Solid lines reflect hypothesized relationships between a sample of therapeutic processes and targeted change principles.Dotted lines demonstrate that therapeutic processes may also impact behavioral adaptation via other change principles thatare not primary targets.

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solely create change via one corresponding principle.Nonetheless, we argue that each of these processeslargely reflects its corresponding target changeprinciple and will be discussed in the followingsections, as such. How each change principle encour-ages the common goal of behavioral adaptation willalso be noted. Specifically, in the following threesections, we propose a set of common changeprinciples and corresponding therapeutic processesthat may bind disparate CBT approaches together intheir goal of behavioral adaptation and, moregenerally, offer a unified voice within an expandingintervention science.

Context Engagementcontext engagement as a change principle

A hallmark change principle of CBTs is to assistclients in engaging new external and internalcontexts to promote the imagining or enacting ofnovel responses that counteract old and well-wornpatterns of maladaptive associations and reinforce-ment. Deficits in establishing adaptive and context-appropriate contingencies, and the inability to learnnew contingencies, represent key difficulties acrossemotional disorders. Indeed, individuals with psycho-pathology often exhibit rigid patterns of contextualengagement that reflect poor behavioral adaptation.For instance, individuals with anxiety disordersdemonstrate impoverished and inflexible repertoires

of behavior that typically function to promote escape,avoidance, or inactivity as a means of attempting tomanage the arising of negative emotions (e.g., Lohr,Olatunji, & Sawchuk, 2007). Similarly, depressedindividuals are less responsive to contexts for reward(e.g., Bogdan & Pizzagalli, 2006) and fail todistinguish between options yielding large versussmall rewards (Forbes, Shaw, & Dahl, 2006). Bycontrast, bipolar spectrum disorders are character-ized by hyperactive behavioral tendencies reflective ofreward and goal systems without regard for contex-tual cues to threat and danger (Alloy et al., 2012).Finally, comorbid anxiety and depressionmay lead todifficulties resolving approach/avoidance valuation,which may result when an individual is unable todetermine the relative value of simultaneous butambiguous safety and reward contextual cues (Stein& Paulus, 2009).Adaptive and flexible behavioral responses are

dependent upon the ability to increase awareness ofcues and contingencies in the environment and emitcontextually appropriate responses that promotesurvival and success. Optimal reward learningrequires us to assign value to possibly rewardingstimuli, make predictions about when and where wemight encounter these stimuli, and take behavioralactions that are informed by these predictions(O’Doherty, 2004). Equally important is learningto accurately detect safety cues and differentiate these

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signals from threat cues so that we do not expendvaluable resources (e.g., time and energy) in attemptsto escape from “nonthreats.” Contemporary modelsof threat and safety learning are predicated onprinciples of classical conditioning (Bouton,Mineka,& Barlow, 2001). One of the most basic directives ofan adaptive organism is to bring balance with respectto engaging reward and minimizing loss whileseeking safety and avoiding threat (Dollard&Miller,1950). Normative functioning represents a constantstate of engaging and resolving conflicts of rewardand threat in service of taking effective behavioralaction. CBT may help promote effective selection ofappropriate and adaptive behavioral actions via theintegration of stored representations, associations,and appraisedmeanings of the rewarding or aversiveproperties of a stimulus with contextual informationfrom the internal and external environment. Thesalient outcomes of this adaptive responding arere-represented and reconsolidated memory storesthat exert important influences on future responseselection (Nader & Hardt, 2009).

therapeutic processes that targetcontext engagement

Behavioral ExposureExposure therapy is integral to CBTs for anxietydisorders (Craske et al., 2008). This approach derivesfromprinciples of classical conditioning, tracing backto thework ofWolpe (1958), and directly encouragesthe engagement of threat-perceived contexts. Rela-tively recent insights into the nature of fear extinctionhave elucidated the mechanisms underlying behav-ioral exposure (Craske et al., 2008). Fear extinctionreflects the unpairing of conditional stimulus (CS)–unconditional stimulus (US) associations but doesnot mean an elimination of the original CS–USassociation. Rather, the significant mechanism ofaction in exposure therapy may be inhibitorylearning (i.e., CS–no US association), whereby newlearning about the CS–US relationship develops thatserves to inhibit the expression of previously condi-tioned responses (Bouton et al., 2001).In the past 50-plus years, exposure therapy has

demonstrated considerable efficacy for patientssuffering from anxiety disorders, and findingscontinue to extend the acute and enduring treat-ment effects to a larger proportion of patients(Craske et al., 2008). In vivo exposures forconditions such as social phobia (Blanco et al.,2010), imaginal exposures for conditions such asposttraumatic stress disorder (Cloitre et al., 2002;Foa, 2011), and interoceptive exposures for condi-tions such as panic disorder (Craske & Barlow,2008) have demonstrated extensive efficacy. In

addition, rCBT approaches have built upon thisfoundation and are showing promise in targetingcontextual changes in response to perceived threats.For example, one important aspect of ACT is thedelineation of values, which reflect construeddesired life consequences, and in turn, help in-dividuals clarify behavioral actions and promotemotivation and endurance of instances such asfacing one’s fears in a variety of contexts, whichmay be successful through the encouragement ofsuperior inhibitory learning (S. Hayes et al., 1999;Wilson & Murrell, 2004). Similarly, many tCBTand rCBT approaches have been infused withmindfulness meditation practices. Treanor (2011)recently reviewed findings and proposed howmindfulness practices improve exposure therapyvia enhanced attention capacity, better discrimina-tion and recall of fear cues, and an increasedtolerance to remain in contact with fearful stimuli.

Behavioral ActivationLike exposure therapy, treatment components com-monly referred to as behavioral activation (BA)represented foundational behavioral efforts to treatconditions such as major depressive disorder (MDD)that predate cognitive-oriented approaches (e.g.,Beck, Rush, Shaw, & Emery, 1979). The BAconceptualization of depression views depressedindividuals as no longer able to engage the behavioralrepertoires capable of delivering positive reinforce-ment in their lives—thereby resulting in depression,withdrawal, and an ever-deepening vicious circle ofdeprivation frompositive reinforcement (Lewinsohn,1974). Ferster (1973) also posited that depressionwas largely a disorder of emotional withdrawal andthat one of the ways that depressed individualsworsened their situation was by inordinately orient-ing their lives in service of escape and avoidance ofaversive situations instead of pursuing opportunitiesfor positive reinforcement. Thus, BA typically con-sisted of interventions including activity scheduling,contingencymanagement, and skills training aswaysof helping individuals gain awareness of the avail-ability of positive reinforcement, emit behaviorscapable of contingently obtaining positive reinforce-ment, and ideally, effecting change in one’s environ-ment to maintain access to positive reinforcers whencertain behavioral responses are provided (Ferster;Kanter et al., 2010; Lewinsohn).Encouraging engagement of reward contingencies

is also part of tCBTs that emphasize cognitiveelements such as the stressing of reward engagementin cognitive rehearsals (Beck et al., 1979) and theidentification of triggers, responses, and alternativecoping responses to promote engagement (e.g.,Martell et al., 2001). Similarly, Kanter and colleagues

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(2010) note that adding values-based work (a centralcomponent of ACT; S. Hayes et al., 1999) canaugment BA treatments, possibly by helping tomotivate and sustain activation behaviors, especiallywhen the reinforcer for that action is not expected tooccur immediately. Focusing on values may alsoprovide a stronger compass for meaningful behavior-al engagement beyond rewards that may be fleeting,not connected to personal meaning, or detrimental inthe long term (e.g., unhealthy desserts, risky behav-iors; S. Hayes et al.). Recent findings from anopen-label trial of BA highlight the role of rewardengagement in the context of recovery from MDD(Dichter et al., 2009). Specifically, 12 MDD patientsunderwent fMRI assessment before and after treat-ment with BA. Findings revealed that 9 of 12 patientswere classified as treatment responders and evidencedgains in self-report reward sensitivity and associatednormalization of neural activity related to rewardselection, reward anticipation, and reward feedback.

Attention Changeattention change as a change principle

Behavioral adaptation requires the ability to flexiblydirect attention via constriction or expansion accord-ing to situational demands. A principle of attentionalchange can be seen as improving one’s ability to focusattention on a target stimulus, sustain attention onthe chosen stimulus, or flexibly move attention todifferent stimuli. The ability to focus attentioninvolves actively choosing the stimulus to which onewill attend (Kabat-Zinn, 2005). The ability to sustainattention refers tomaintaining this focus on the targetstimuli (see Posner & Rothbart, 1992) as well asactively redirecting attention back to the target stimuliwhen attention has wandered (e.g., Smallwood &Schooler, 2006). The ability to flexibly moveattention entails leading attention to various differentaspects of an experience (Szymura, Smigasiewicz, &Corr, 2007).Several converging lines of research suggest that

reduced attentional flexibility and rigid attentionalbiases towards negative or threatening information,as well as difficulty disengaging from negative stimulidifferentiate individuals with numerous psychopa-thologies from healthy controls and reflect keycharacteristics of emotional disorders (e.g., Joormann& Gotlib, 2007; Mathews & MacLeod, 2005). Assuch, numerous CBTs directly and indirectly targetchanges in attentional processing. Increasingattentional flexibility involves adapting attentionalresponding to varying contexts. Constricted, nar-rowly focused attention is adaptive during times ofpotential threat (i.e., concentrating resources on thethreat and facilitating the selection and mobilizationof appropriate responses; Friedman & Forster,

2010), but when no threat is present, broadenedattention is more adaptive (facilitating exploratorybehavior and allowing for the detection of newinformation and novel incentives; Friedman &Forster, 2010). Hyper-responsivity towards threat-ening information and attentional bias occur withinmilliseconds, and appear to influence further pro-cessing almost immediately (Mathews & MacLeod,2005). As such, early processing biases towardsthreat are followed by reduced processing of threator increased avoidant responding (see Hofmann,Ellard,&Siegle, 2011, for review).Disruptions in theearliest perceptual processing of stimuli set inmotionregulatory control attempts and behavioral attemptsto dampen responding (e.g., gaze aversion; Garner,Mogg, & Bradley, 2006).Improving directed attention to external stimuli

might aid in freeing an individual from passivelyattending (i.e., “mind wandering”; Smallwood &Schooler, 2006) to assumptions, predictions, evalua-tions, and other elaborative responding triggered by agiven environmental context. Indeed, greater aware-ness of one’s environment may facilitate action that ismore flexible and adaptive for the current situation.Targeting directed attention to internal, nonverbalstimuli might improve one’s awareness of personalexperiences as they unfold. For instance, whenattending to an emotion such as sadness, individualscan develop the capacity to attend to one’s body andnotice the sensory qualities rather than cognitivelyappraising the emotion and engaging in rumination inresponse to the emotion (Farb et al., 2007).

therapeutic processes that promoteattention change

Attention TrainingAlthough many tCBTs and rCBTs reduce atten-tional biases (Mathews & MacLeod, 2005), recentCBT interventions specifically work to increaseattentional flexibility. Recent attentional bias mod-ification (ABM) studies find an increased ability toimprove directed attention away from a hypervigi-lant threat focus and subsequent improvement insymptoms and impairment, particularly for anxietydisorders (e.g., Amir et al., 2009; however,numerous meta-analyses have recently challengedwhether this approach establishes durable efficacy;see Hallion & Ruscio, 2011, for one suchmeta-analytic example). In ABM, participantswho were trained to attend away from threateningcues using a modified dot-probe paradigm showedan increased ability to disengage from threat-relatedcues, changes in attention bias, and a decrease indistress as indicated by self-report and interviewermeasures.

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Therapeutic processes that utilize mindfulnesstraining also promote attentional flexibility.Mindfulawareness training has been increasingly incorporat-ed into psychological treatments as a method ofpromoting a level of open awareness that is intendedto increase the objective, present-moment perceptionof internal and external cues (Baer, 2003). Exercisesthat target attention change include mindfulness ofemotions, in which the client brings to mind anemotionally provocative situation and observes,allows, and directs attention towards his or herinternal, emotional experience (see Mennin &Fresco, 2009; Orsillo & Roemer, 2011; Segal et al.,2002) andmindfulness of senses and the body,whichinvolve the client visualizingwhat the emotionwouldlook like and feel like if it could be tangiblyencountered through the senses (see S. Hayes et al.,1999; Segal et al., 2002). Engaging in formalmindfulness training reduces depressive symptomsand rumination while improving sustained attention(e.g., Chambers, Lo, & Allen, 2008) and perceptualsensitivity (e.g., MacLean et al., 2010).

Acceptance/ToleranceIn addition to processes that centrally train directedattention, interventions that promote emotionalacceptance and tolerance primarily target attentionchange by encouraging sustained contactwith feelingstates without being dissuaded by elaborativethought processes that promote disengagement andavoidance (e.g., maintaining attendance to visceralaspects of emotionswithin the bodywithout labelingor judging; see S. Hayes et al., 1999; Linehan, 1993;Segal et al., 2002). Although treatment researchisolating emotional acceptance and tolerance pro-cesses is limited, increases in self-reported acceptanceof difficult inner experiences (including emotionalexperiences) is associated with positive treatmentoutcomes (e.g., Forman, Herbert, Moitra, Yeomans,& Geller, 2007; McCracken, Vowles, & Eccleston,2005). Similarly, lab-based measures of distresstolerance predict early dropout in residential sub-stance abuse treatment (Daughters et al., 2005)whereas improvements in clinical outcome anddistress tolerance occur when targeted by treatmentsdesigned to improve distress tolerance skills(Bornovalova, Gratz, Daughters, Hunta, & Lejuez,2012).Promoting acceptance and tolerance of emotions is

a core component of rCBTs such as ACT and DBT.In ACT, clients are encouraged to notice the functionof their thoughts and actions in terms of how theymay promote distraction, attentional constriction,and overall “experiential avoidance” (see S. Hayes etal., 1999). ACT therapists then help clients worktowards broadening their focus to allowall aspects of

experience regardless ofwhether these feel difficult oraversive. Clients are encouraged to notice, describe,and maintain contact with an aversive internalexperience (i.e., bodily sensation, feeling, thought,memory) as well as notice any efforts to constrict,disengage, or avoid these experiences. In DBT,distress tolerance skills promote an allowance ofdistressing emotions by encouraging a “wise mind”attendance of internal experience that is not whollyengaged and consumed (i.e., “emotional mind”) norfully disengaged (i.e., “reasonable mind”) but ratheris characterized by the simultaneous noticing of bothurges to engage and disengage. Clients are thenencouraged to utilize a series of tolerance skills toallow their difficult emotional experience whilebroadening attention to other aspects of theirexperience that are less negatively emotionallyladen (see Linehan, 1993).

Cognitive Changecognitive change as a change principle

Cognitive change refers to the ability to change one’sperspective on an event so as to alter verbalmeaningsand their emotional significance (Gross, 2002). Twotypes of cognitive processing are particularly impor-tant, namely, cognitive distancing and cognitivereinterpretation. Cognitive distancing can be definedas a metacognitive ability to observe items that arisein the mind (e.g., thoughts, feelings, memories, etc.)with healthy psychological distance, greater self-awareness and perspective-taking, and the recogni-tion that one’s thoughts, feelings, and urges aresubjective, transient internal events rather thaninherent, permanent aspects of the self or accuraterepresentations of reality (Fresco, Moore, et al.,2007; Fresco, Segal, et al., 2007; Segal et al., 2002).Cognitive distancing helps individuals disengagefrom an intense emotion, its corresponding motiva-tional impetus, and associated maladaptive self-referential processing in favor of a more experientialperspective with respect to personally relevantemotionally laden information (Farb et al., 2007).Promoting distance from the self in time

(e.g., viewing inner experiences as temporary;Watkins, Teasdale, & Williams, 2000), distancefrom the self in space (e.g., viewing inner experiencesas physical objects that are separate from oneself;e.g., Kalisch et al., 2005), or distance from the self inpersonal perspective (e.g., viewing inner experiencesas not inherent to one’s self-concept; Farb et al.,2007; Kross & Ayduk, 2009) is associated withpsychological benefits. Further, a distanced perspec-tive from aversive stimuli can decrease psychologicaldistress (e.g., Davis, Gross, & Ochsner, 2011) andthe believability of negative, self-relevant thoughts(Masuda et al., 2010). Fresco,Moore, and colleagues

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(2007) found cognitive distancing to be negativelyrelated to self-report measures of depressive symp-toms, anxiety symptoms, depressive rumination,experiential avoidance, and expressive suppression.Conversely, studies on individuals with psychopa-thology have found distress-reducing benefits fromexperimental techniques designed to promote anobservational distance from the self (Farb et al.;Kross & Ayduk). Further, distancing manipulationshave also been shown to reduce depressotypicthought accessibility, diminished emotional recount-ing, and increase accuracy of reconstruals of pastevents in individuals who are depressed (Kross,Gard, Deldin, Clifton, & Ayduk, 2012).Another form of cognitive change is cognitive

reinterpretation of situations or circumstancesin one’s life. Three common forms of cognitivereinterpretation include realistic reappraisal(e.g., reevaluating an event in a more accurate,objective, factual manner while remaining sensitiveto contextual factors; Ray, Wilhelm, & Gross,2008), positive reappraisal (e.g., reevaluating anevent in a manner that orients towards possibledesired, rewarding, or beneficial aspects of the eventor consequences of the event that may have beenoverlooked in the original appraisal; Ray et al.,2008), and compassionate reappraisal (e.g., reeval-uating an event in a manner that appreciates thateither oneself or another is in emotional pain,validates the pain, desires to alleviate the pain, andidentifies the pain as a natural aspect of the humanexperience; Leary, Tate, Adams, Batts, & Hancock,2007).Laboratory-based studies of cognitive change

report psychological benefits from instructing par-ticipants to reappraise emotional stimuli or tasks in amanner designed to diminish personal identificationand increase objectivity before the individualsencounter the stimuli or task (e.g., Gross, 2002;Hofmann et al., 2007). Studies have found distress-reducing benefits from inducing realistic/objectivereappraisal (e.g., Ray et al., 2008), positive reapprai-sal (e.g., Ray et al.), other-focused compassionatereappraisal (e.g., Witvliet, DeYoung, Hofelich, &DeYoung, 2011), and self-focused compassionatereappraisal (e.g., Leary et al., 2007) of personallyemotionally provocative events. For instance, asubstantial literature has shown that viewing avideo of oneself is only useful in changing self-evaluation of performance and/or anxiety in thosewith social anxiety if one does so from the reapprais-ing perspective of a third party (e.g., Rodebaugh,Heimberg, Schultz, & Blackmore, 2010). Difficul-ties implementing cognitive change appear to charac-terize various forms of psychopathology (Aldao,Nolen-Hoeksema, & Schweizer, 2010). A capacity

to change cognitions and relinquish one’s originalinterpretation may undermine passive, repetitiveelaborative processes central to transdiagnostic psy-chopathology (e.g., rumination; Nolen-Hoeksema,Wisco, & Lyubomirsky, 2008) and promote flexibil-ity that allows formore effective, rather than habitual,behavioral reactions. Indeed, reappraisal has beenfound to be positively associated with a number ofindices of well being, including effective interpersonalfunctioning (Gross & John, 2003).

therapeutic processes that promotecognitive change

Decentering/DefusionMany therapeutic processes of tCBTs and rCBTs(e.g., Beck et al., 1979; S. Hayes et al., 1999; Safran& Segal, 1990; Segal et al., 2002) promotecognitive distancing, albeit by different means. Forexample, the common CBT practice of instructingclients to self-monitor distressing thoughts andemotions and write down these experiences likelyencourages observing, distancing, and labeling ofemotional meanings. More directly, mindfulnessand acceptance-based perspectives (e.g., S. Hayes etal.; Roemer & Orsillo, 2009; Segal et al., 2002)target cognitive distancing through various exer-cises such as mindfully noticing inner experiences orvisualizing inner experiences as objects. Promotingtemporal distance can be accomplished with“decentering” practices such as the mountainmeditation (Kabat-Zinn, 1994), a mindfulnesspractice to help clients gain temporal perspectiveon a difficult emotional state by imagining them-selves as a sturdy mountain that is continuallyawash in the effects of changing climates andseasons yet essentially still, consistent, and ground-ed. Thus, clients are able to decenter when theyrecognize that emotional storms, like real ones, areexperiences rather than defining entities. Promotinga sense of spatial distance can be encouraged bypractices such as the observer exercise or “carryingyour keys” in ACT (S. Hayes et al.). In thesepractices, clients learn to notice internal emotionalprocesses (i.e., emotional sensations, thoughts,memories) as a component or part of experiencerather than defining characteristics.Teasdale and colleagues (2002) found that

MBCT resulted in larger increases in decenteringas compared to treatment as usual. Further, self-reported decentering predicts acute treatment re-sponse inMDD following cognitive therapy but notmedication (Fresco, Segal, et al., 2007), durabilityof treatment gains (Fresco, Segal, et al.), and in theprevention of MDD relapse following MBCT(Bieling et al., 2012). Findings from an fMRI

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study on a subset of patients from the Bieling et al.trial revealed that hyperactivation of medial pre-frontal regions implicated in self-referential pro-cessing predicted earlier relapse whereas increasedactivation in visual processing regions, interpretedas a capacity to observe emotionally evocativepercepts, predicted treatment durability (Farb,Anderson, Bloch, & Segal, 2011).As S. Hayes and colleagues (2013–this issue)

explain, clients can be encouraged to practice asimilar form of cognitive distancing called defusion,which involves perspective taking on the impact oflanguage-reinforcing associations. For example,clients might be encouraged to say, “I am havinganxiety right now” instead of “I am anxious.”Zettle, Rains, and Hayes (2011) compared groupACT versus group cognitive therapy in the treat-ment of MDD and found that the differentialimpact of treatment condition on depressive symp-toms at follow-up was mediated by self-reporteddecreases in the believability of depressogenicthoughts at posttreatment, which was used as anindication of increases in cognitive defusion. It isunclear, however, if cognitive distancing as op-posed to reframing (see below) was the activeprocess of change given the limits of self-report.

Cognitive ReframingReappraisal is a central focus of reframing inter-ventions in tCBTs. One way that CBT therapistspromote reframing is to encourage clients tomonitor and interpret emotionally provocativeevents. When interpretations are found to beunrealistic or unhelpful, the therapist helps clientschallenge the ascribed meaning through logicalquestioning, identification of cognitive “distortions”(i.e., interpretations that are not based on logic), andencourage clients to generate new possible meaningsthat are more rational and realistic (i.e., “restructur-ing”; e.g., Beck et al.). Behavioral experiments canalso elucidate how unhelpful or unrealistic meaningsascribed to events are not in line with whatobjectively occurs (e.g., Beck et al., 1979). Also,cognitive change is accomplished by providingpsychoeducation to assist clients in identifying“thinking traps” in their appraisals, and generatingalternative appraisals (e.g., Barlow et al., 2011).Although treatment research isolating reframinginterventions is limited, Goldin et al. (2012) foundthat increases in cognitive reappraisal self-efficacymediated CBT treatment efficacy. In a recentmeta-analysis testing the role of threat reappraisalin symptom change from cognitive behavioraltreatment of anxiety disorders, Smits and colleagues(2012) found that a small majority of these studieshad established statistical mediation but only a few

studies had established that threat reappraisalpreceded anxiety reduction and even fewer demon-strated specificity in this effect.CBT therapists can also generate meaning change

by helping clients to reframe via self-compassionatereappraisal. Techniques designed to enhance self-compassion include clients imagining telling a verycaring, interested, compassionate individual abouttheir difficult thoughts and feelings, clients askingthemselves factual questions about the reality oftheir situation in a caring, nonjudgmental, andunderstanding manner, clients reminding them-selves of their strengths and coping ability, clientsempathically reflecting on the perspective of othersinvolved in the situation, and clients offeringsoothing, helpful alternative thoughts while talkingto themselves in the mirror (see Gilbert, 2009). CBTtherapists have also incorporated loving-kindnessmeditation, in which clients imagine extendingkindness to loved ones, to themselves, to neutralpeople or strangers, to individuals who have causedthem harm, and to all living beings (e.g., Salzberg,1995). Other exercises include the observation ofself-critical thoughts and subsequent application ofa statement of self-validation and self-compassion(see Mennin & Fresco, 2009, adapted from Segal etal., 2002).Although ACT does not encourage challenging of

thought content, it does emphasize the use ofdescriptive metaphors or analogies that encouragechanging of perspectives on difficult emotionalexperiences from one of requiring avoidance andescape to one of viewing them as natural responsesthat are best allowed and not overly controlled(e.g., visualizing “dropping the rope” in a tug ofwar with an “anxiety monster”; “chess metaphor”;see S. Hayes et al., 1999). In other words, althoughACT focuses on the concept of acceptance in itsmore metaphorically focused interventions, whatmight best account for change in these particulartechniques is the implicit reframing of cognitionsabout the averseness of emotional experience andthe need for it to be controlled. However, it isimportant to emphasize that cognitions are notreframed according to direct analysis but ratherthrough an invitation to consider an alternativeviewpoint about the struggle to reduce suffering.

The Broader ContextThepast 50 years have seen considerable advances inthe treatment of mental disorders. CBT has beenparticularly instrumental in developing treatmentsthat alleviate the suffering associated with many ofthese conditions. Despite these advances, disorderscharacterized by high levels of comorbidity, unyield-ing course, and poor life satisfaction remain refractory

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to existing treatments. To meet these challenges, wehave witnessed exciting new developments in multi-componential behavioral approaches (e.g., ACT),alternative therapies (e.g., meditation), briefer, moretargeted and cost-effective, technologies, and theintegration of biological and behavioral frameworksof change. These changes reflect a widening, increas-ingly multidisciplinary, intervention science. Al-though competition and disunity are naturalresponses to a diversifying field, a lack of cohesionlimits opportunities for the CBT field to align in ashared vision and a common language to offer theseCBTs to the larger community.To promote this shared vision and common

language, we have suggested that CBTs are charac-terized by (a) a common goal of behavioraladaptation; (b) common change principles ofcontext engagement, attention change, and cognitivechange to realize this behavioral adaptation goal;and (c) common therapeutic processes that can beseen as differentially reflecting each of theseprinciples. Specifically, we have argued that toachieve a common goal of behavioral adaptation,CBTs share change principles that target respondingat different points along an emotional trajectory(Gross, 2002), including context engagement, whichcan be seen as encompassing therapeutic processesof behavioral exposure and behavioral activation;attention change, which can be seen as encompass-ing therapeutic processes of attention training andacceptance/tolerance; and cognitive change, whichcan be seen as encompassing therapeutic processesof decentering/defusion and cognitive reframing.Advancing core characteristics of CBT within an

intervention science framework will require changesin research design and practice. One importantchange is in how we determine how our interven-tions produce change—what is often termed mech-anisms. Throughout the history of CBT, differentapproaches have focused on mechanisms defined bytheir intervention philosophy. However, we arguethat efforts to demonstrate how a treatment pro-duces clinical improvement should reflect commontarget mechanisms such as those that might underliebehavioral adaptation (e.g., inhibitory learning;Craske et al., 2008). Further, it will be importantto examine target mechanisms with rich biobehav-ioral marker assessments (e.g., behavioral tasks,functional magnetic resonance imaging, psycho-physiology) that have established reliability andvalidity in lab and analogue studies. This approachaligns CBT mechanism research with the growingmultidisciplinary field of intervention science as wellas with NIMH priorities such as the ResearchDomain Criteria initiative (i.e, “RDoC”; Sanislowet al., 2010) since it is agnostic to treatment theory

and can help elucidate biobehavioral markers thatare reliably dissociable in patient subgroups ascompared to healthy controls. Also, assessingcommon target mechanisms in various approachesmay help us better understand patient characteristicsthat predict treatment success and failure (e.g.,treatment matching, treatment optimization/aug-mentation; NIMH Council’s treatment personaliza-tion initiative; Kraemer et al., 2002).It will also be important to test the role of

common change characteristics in differing inter-vention contexts. Traditional methods, such asRounsaville, Carroll, and Onken’s (2001) stagemodel, provide established frameworks for deter-mining how a treatment produces change and whatare the most important core components. Typically,this involves successive tests of the efficacy of atreatment and later determination of core processesthrough dismantling designs. However, CBT alsohas a rich history of undertaking laboratory andanalogue studies that inform treatment develop-ment. As S. Hayes and colleagues (2013–this issue)have argued, laboratory studies can test whether aspecific intervention process produces meaningfulchange in a given targeted mechanism via a morecontrolled environment. This approach is ultimate-ly more cost-effective than waiting to establishefficacy before testing how and why a treatmentworks. Laboratory paradigms that show promise indelineating common processes and mechanismscould be utilized within trial research to determinehow these factors produce and mediate behavioraladaptation as a result of a given intervention.One concern is that existing treatments are quite

heterogeneous and, thus, it might be difficult toisolate the role of common characteristics. AsDobson (2013–this issue) notes, CBT packagesare technically eclectic (i.e., comprised of heteroge-neous components), thereby complicating the iden-tification of key principles and processes that leadto successful outcome, let alone differentiate howthis is achieved in a given treatment versus another.In response to this issue, briefer, more homoge-neous interventions have emerged (e.g., ABM; Amiret al., 2009). However, questions remain whetherbriefer means better in terms of improved efficacyor, more importantly, the ability to target the fullspectrum of psychopathology in many conditions(e.g., see Hallion & Ruscio, 2011, for onemeta-analytic example that calls into question theability of ABM to provide durable efficacy forcomplex conditions). Indeed, conditions withdysfunction in multiple mechanisms may requirelonger, multi-process, approaches given greatercomplexity and refractory intervention response(e.g., anxious depression; Fava et al., 2008).

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Thus, it will be important to have a sharedlanguage for assessing common principles andprocesses in approaches and modalities that differin focus and scope. Adherence has typically reflectedthe measuring or coding of behaviors or actions onthe part of the therapist related to the delivery ofspecific techniques in a treatment package. Howev-er, we may better serve the field by examiningadherence and integrity at the level of commonchange principles and therapeutic processes (Rosen& Davison, 2003). This endeavor would involvedeveloping a core battery of items related toprinciples and processes. For instance, adherenceto context engagement could include items related towhether the intervention directly encouraged en-gagement of new behaviors and whether these weretowards threatening or rewarding internal orexternal environments. However, given variabilityof treatments in their levels of heterogeneity, it willalso be important to also index parsimony. Cougle(2012) has pointed out that more parsimonioustreatments require less formal training in order toimplement, lead to greater integrity and adherence,and are, thus, able to have superior outcomes.Ideally, therapies, according to Cougle, will befeasible for different settings, least aversive, as briefas possible, and cost effective. Thus, heterogeneoustreatments may be necessary for some conditions butin addition to measuring how they reflect commoncharacteristics, it will also be important to determinetheir parsimony, ease, and efficiency (Cougle, 2012).The model of common change characteristics that

we have provided is by nomeans exhaustive. Instead,it represents an initial attempt to provide scaffoldingfor seemingly diverse CBT approaches to findcommon ground in the purposes and targets oftheir interventions. Of course, philosophical differ-ences underlying these therapeutic processes can behonored and modeled when examining commoncharacteristics. For instance, the role of responsemodulation was not addressed given our view thatit is not a common principle of change. However,given the efficacy of therapeutic processes that targetresponse modulation, especially in child and cogni-tively challenged populations where therapeuticprocesses reflective of other change principles(e.g., attention change, cognitive change) may bemore difficult, it may be important to determinethe role of response-modulation-based change prin-ciples and whether these can be targeted from acommonCBTperspective. Indeed, a recent extensionof applied relaxation from an acceptance perspectivesupports this possibility (e.g., Hayes-Skelton et al.,in press). Further, there are likely other commonchange principles and processes that CBT ap-proaches encompass. Those offered in this article

and other possible characteristics of change will beimportant to further examine both empirically andtheoretically. As this special series has demonstrated,there are exciting new developments in both tCBTsand rCBTs. We hope that by developing a commonframework, we can honor these developments butalso CBT as an integrated whole and step forward ina new age of intervention science with a strong andunified voice.

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