Editorial
Towards an understanding of the process and mechanisms of change in cognitive behavioral therapy: Linking innovative methodology with fundamental questions

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Acknowledgements

Preparation of this paper and series was supported by National Institute of Mental Health grant R21MH062662 awarded to the first author and National Institute of Mental Health fellowship 1F31MH071071-01 awarded to the third author.

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    Yet, very little is known about which elements within treatments are most associated with symptom improvement, required dose for any treatment or element within a treatment, and essential versus non-essential elements of multi-element treatments. Progress towards understanding “essential ingredients” within psychological treatments could lead to further refinement of existing treatments to aid in efficiency for greater public health impact (Hayes, Hope, & Hayes, 2007; Huebner & Tonigan, 2007). By understanding more about which elements help reduce symptoms, treatments could be optimized by: 1) a more focused use of elements, specific combinations of elements, and/or guidance on appropriate dosing ranges, 2) a reduction in the proliferation of manuals, which in turn would reduce the time and money to evaluate multiple new interventions, and 3) a reduction in time/resources required for training and supervision, if fewer elements are necessary for symptom reduction (e.g., 3–4 vs. 9 or more).

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    These sudden changes resemble many clinical phenomena in mental health, such as sudden relapse in recovered substance users (Witkiewitz & Villarroel, 2009), mood instability in bipolar disorder (Bonsall, Wallace-Hadrill, Geddes, Goodwin, & Holmes, 2012), shifts in perceptual dynamics across phases of psychotic breaks (Tschacher & Junghan, 2009), the timing and frequency of compulsive rituals in obsessive-compulsive disorder (Bond & Guastello, 2013; Yaniv, 2008) or the large improvements observed frequently between single sessions in empirically-supported brief therapies (i.e., “sudden gains”, e.g., Tang, DeRubeis, Hollon, Amsterdam, & Shelton, 2007). Thanks to these, and many other, contributions, researchers have increasingly recognized the inherent nonlinearity of most psychotherapeutic changes (Hayes, Hope et al., 2007; Pincus, 2009; Salvatore & Tschacher, 2012), while the field as a whole has shifted over the last two decades toward an increasing appreciation of processes of change (Crits-Christoph, Connolly Gibbons, & Mukherjee, 2013; Gonçalves, Ribeiro, Mendes, Matos, & Santos, 2011; Nitti, Ciavolino, Salvatore, & Gennaro, 2010; Wampold, 2001). For example, Baldwin, Berkeljon, Atkins, Olsen, and Nielsen (2009) assessed the process of change in a naturalistic study in more than 4,000 individuals who received counseling.

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