History and evolution of cbt: from the first to the third generation - cognitive behavioral therapy

Cognitive-behavioral therapy has followed a path of several decades, integrating findings from learning psychology, cognitive science and, more recently, the contextual sciences. Across three major generations, it has refined its way of understanding human suffering and intervening on it, moving from changing observable behaviors to working with thoughts, emotions, attention, values and the relationship with one’s own internal experience. This journey helps explain why there are today multiple variants under the umbrella of a common approach: being pragmatic, evidence-based and focused on processes that explain change.

Behavioral roots: the first generation

Classical and operant conditioning

The origins lie in behaviorism, which sought to explain behavior based on observable learning laws. Classical conditioning showed how neutral stimuli can acquire the power to evoke emotional responses; operant conditioning explained how consequences (reinforcement or punishment) shape the probability that a behavior will be repeated.

From this framework arose systematic techniques such as exposure to reduce fear responses, desensitization, reinforcement programs to increase adaptive behaviors and behavioral contracts. Assessment relied on direct observation, functional analysis stimulus–response–consequence and objective measures of change.

Achievements and limits of the first wave

This stage achieved notable advances in problems such as specific phobias, enuresis, tics or habits, and established a standard of methodological clarity: define target behaviors, intervene and measure. However, its focus on the observable left little room for language, beliefs, memory and personal meaning. Many clinicians and patients felt that a piece was missing: how people interpret their world.

The cognitive revolution: the second generation

From automatic thoughts to schemas

The cognitive wave introduced the idea that the way of thinking directly influences how we feel and act. Automatic thoughts, attentional biases, intermediate beliefs and core schemas that shape experience were described. The therapeutic goal broadened to identify and modify maladaptive thinking patterns to produce emotional and behavioral changes.

Emblematic techniques and evidence

Resources such as thought records, cognitive restructuring, behavioral experiments, downward arrows to reach core beliefs and psychoeducation based on clear models of each problem were consolidated. Randomized controlled trials demonstrated efficacy in depression, anxiety disorders, eating disorders and others, which positioned CBT as a benchmark for evidence-based interventions.

Criticisms and challenges

Although powerful, the second generation was questioned when the exclusive focus on “disputing” the content of thoughts proved insufficient in complex or chronic problems. Some people perceived rational discussion as an endless struggle with their mind. Additionally, cultural diversity and individual differences highlighted that not everyone changes in the same way or through the same mechanism.

The third generation: contextual and acceptance-based therapies

Mindfulness, acceptance and psychological flexibility

The third wave does not abandon what has been learned, but it changes the question: instead of trying to control or eliminate internal events, it invites changing the relationship with them. It introduces processes such as mindfulness, acceptance, cognitive defusion and contact with the present moment. The goal is to increase psychological flexibility: to respond effectively to internal experiences and to environmental demands, in the service of what the person values.

• Acceptance and Commitment Therapy: emphasis on values, committed action and defusion.
• Dialectical Behavior Therapy: balance between acceptance and change, with skills in mindfulness, emotion regulation, distress tolerance and interpersonal effectiveness.
• Mindfulness-Based Cognitive Therapy: relapse prevention in depression by combining mindfulness with cognitive elements.
• Behavioral Activation: a return to behavioral principles to break cycles of avoidance and anhedonia through scheduling of valuable activities.
• Functional Analytic Psychotherapy and other variants focused on the function of behavior in context.

Values and committed action

A key aspect of this stage is orienting the intervention according to what matters to each person. Clarifying values defines long-term directions (beyond pinpoint goals) and guides skill practice, exposure and decision-making. Motivation is not conceived as a state prior to change, but as something that is strengthened by acting consistently with those values.

Emotion regulation and dialectical integration

DBT showed that accepting experience and validating suffering can coexist with actively working to change harmful patterns. This dialectic proved crucial in high-risk behaviors, impulsivity and attachment difficulties. Structured skills training made a difference for complex populations where purely cognitive or behavioral interventions were insufficient.

Continuities and changes across generations

What remains

• Commitment to empirical evidence and measurement of change.
• Individualized case formulation and functional analysis of behavior.
• Use of between-session tasks, exposure and behavioral experiments.

What changes

• From content to process: less “what I think” and more “how I relate to what I think.”
• From control to strategic acceptance: choosing battles with the mind instead of fighting them all.
• From disorder-based protocols to transdiagnostic processes: attention, avoidance, cognitive fusion, emotion regulation.
• Greater valuation of the therapeutic alliance and of the cultural and social context.

Clinical impact and current applications

Problems and populations

The current field covers anxiety, depression, personality disorders, psychosis, chronic pain, addictions and medical conditions with behavioral components. In children and adolescents, skills-based approaches and behavioral activation show good applicability. In older adults, pacing and formats are adapted while maintaining the focus on values and functionality.

Technology and new formats

Formats such as teletherapy, digital CBT programs, apps to practice skills and virtual reality for exposure have expanded. These resources increase access and allow real-time data monitoring, although they still require clinical judgment and individual adaptation.

Evidence, processes and the future direction

From protocols to processes

Research is moving toward identifying mediators and moderators of change. Instead of asking “which protocol for which diagnosis,” the question is “which process for which person in this context.” This drives briefer, more focused and personalized interventions, along with continuous progress assessments.

Synergies with neuroscience and behavioral sciences

Dialogue with cognitive neuroscience and behavioral economics adds understanding of biases, habits and decision-making. Tools such as ecological momentary assessment of mood, biofeedback or analysis of sleep and activity patterns help turn data into finer therapeutic decisions.

Therapist training and the therapeutic relationship

Attention to therapist competencies is growing: delivery skills, flexibility, deliberate practice and use of feedback. The therapeutic relationship is not just a “context” but a mechanism that can be trained, observed and improved, influencing adherence and outcomes.

How to choose the right approach for each person

Practical criteria

• Patient goals and values: what life they want to build and what obstacles impede it.
• Dominant patterns: avoidance, rumination, impulsivity, emotion dysregulation, fusion with thoughts.
• Resources and preferences: tolerance for exposure, affinity for mindfulness exercises, availability for tasks.
• Severity and safety: prioritize stabilization and skills in high-risk cases.
• Cultural and social context: adapt language, metaphors and practices to local meanings.

Signs of good practice

• Clear and shared formulation that guides the intervention.
• Periodic measurement of symptoms and processes, with adjustments based on data.
• Balance between acceptance and change: space to feel and to act.
• Training in concrete skills relevant to everyday life.
• Maintenance and relapse prevention plan focused on values and early warning signs.

The evolution through these three generations is not a series of replacements, but a progressive integration. The behavioral legacy contributes clarity and empirical proof; the cognitive revolution added a map of thought; contextual therapies taught how to relate differently to internal experience and to live in service of what matters. Together, they offer a flexible repertoire to respond to human complexity with rigor, humanity and practical sense.