The Third Wave of CBT
The approaches of the first two generations of Behavioral Therapy (BT) share the assumption
that certain cognitions, emotions and physiological states lead to dysfunctional behavior and,
therefore, therapeutic intervention is aimed at eliminating, or at least reducing, these
problematic internal events. Third wave therapies are expanding their targets from the mere
reduction of symptoms to the development of skills aimed at significantly improving the quality
and quantity of activity in which the patient finds value. Even with seriously ill patients, the
new behavioral therapies emphasize empowerment and increase in skills and behavioral
repertoires that may be used in many contexts (Hayes, 2004).
The emphasis on building healthy behavioral skills, finds its rationale in the assumption that
the processes which the patient fights against constantly (judging and attempting to control
their internal experiences) are the same as those experienced by the therapist (Hayes, 2004);
resulting in the fact that the methods and techniques of these therapies are suitable as much
for the therapists as they are for the patients. In efforts made by the patient to increase
acceptance of their internal experiences, the therapist is encouraged to form a sincere rapport
with the inner most experiences of the patient.
Another feature of these new treatments is to break some of the historical barriers between
behavior therapy and the somewhat less scientifically based approaches (e.g. Psychoanalysis,
Gestalt therapy and Humanistic therapies) trying to integrate some of their fundamental
concepts.
If, for some, the above elements suggest the emergence of a new wave within the field of CBT,
for others (e.g. Leahy, 2008; Hofmann, 2008) it is neither a paradigm shift, nor do the therapies
have features that confer any greater clinical efficacy. Whilst standard CBT meets the criteria of
Empirically Supported Therapies (ESTs) — that is, therapies that have been proven effective
through randomized controlled trials — for a wide variety of psychological disorders (Butler,
2006), currently we cannot say the same for the approaches seen in third-generation therapies
(Öst, 2008).
Strong supporting evidence that Acceptance and Commitment Therapy (ACT), one of the most
studied third wave approaches, is more effective than Cognitive Therapy is for the most part
lacking and, when present, is derived from studies that have severe limitations, such as a small
sample size or the use of non-clinical samples (Forman, 2007). So the doubt remains whether
the third generation therapies actually represent a “new” wave in CBT. Keeping this is mind; it
may be interesting to reflect on commonalities and differences between the third generation
and the previous two generations.
The first generation’s exposure techniques were one of the most effective tools in the arsenal
of CBT. Even though the underlying mechanism for this has yet to be fully understood
(Steketee, 2002; Rachman, 1991), the rationale behind exposure techniques are reminiscent of
the extinction processes of avoidance responses through the activation of habituation
processes to the stimulus, with a progressive reduction and eventual disappearance of the
physiological and behavioral reactions associated with them so that the patient learns to cope
with the emotions triggered by the feared situations without resorting to avoidance behaviors.
Since experiential avoidance is a central target in third wave approaches, exposure therapy is
undoubtedly still widely used; However, although third generation approaches can be similar to
those of the previous generations, in terms of exposure techniques, the rational and objectives
are different. Patients, in fact, are helped to identify what really matters in their lives and to
engage in actions that are in line with these aims and values.
It is inevitable that such techniques may elicit unpleasant thoughts, emotions and physiological
sensations, resulting in the impulse to avoid the experiential event. Therefore, third generation
approaches are intended to reduce the avoidance behavior and increase the patient’s
behavioral repertoire, however not necessarily extinguishing the internal responses (even
though the process of extinction may well take place), but accepting them for what are without
going against them.
The role attributed to life experiences in helping to create the content of thoughts is a similar
concept in both second and third generations, but then there are radical differences with
respect to the importance attributed to thought content in the creation and maintenance of
psychological disturbances. Starting with the assumption that a stimulus can affect the
emotions of a patient only as a consequence of how that emotion is processed and interpreted
by his cognitive system, cognitive therapies aim to bring about a change in the patient through
the correction of the content of his dysfunctional thoughts; in contrast, third wave therapies
state that an excessive focus on the content of thoughts may contribute to worsening of
symptoms. Leahy (2008) criticizes this position, citing the amount of empirical research
supporting the greater efficacy of cognitive psychotherapy when compared to any other
therapeutic approach. On the other hand, while reflecting on the new elements of the third
generation, Leahy (2008) admits that the techniques which bring about distancing from ones
thoughts through acceptance and mindfulness do not differ significantly from the process of
critical thinking, which is the technique used in the cognitive approach.
In conclusion, standard cognitive therapy, which aims to modify the content of thoughts, may
hinder the patient’s acceptance of internal experiences; the solution to which has been
proposed through the methods and approaches of the third wave. These approaches put
forward the idea of changing the patient’s relationship with their own internal events, a
process that can be integrated into standard CBT (Hayes, 1999, and Segal, 2002).
The approaches of the first two generations of Behavioral Therapy (BT) share the assumption
that certain cognitions, emotions and physiological states lead to dysfunctional behavior and,
therefore, therapeutic intervention is aimed at eliminating, or at least reducing, these
problematic internal events. Third wave therapies are expanding their targets from the mere
reduction of symptoms to the development of skills aimed at significantly improving the quality
and quantity of activity in which the patient finds value. Even with seriously ill patients, the
new behavioral therapies emphasize empowerment and increase in skills and behavioral
repertoires that may be used in many contexts (Hayes, 2004).
The emphasis on building healthy behavioral skills, finds its rationale in the assumption that
the processes which the patient fights against constantly (judging and attempting to control
their internal experiences) are the same as those experienced by the therapist (Hayes, 2004);
resulting in the fact that the methods and techniques of these therapies are suitable as much
for the therapists as they are for the patients. In efforts made by the patient to increase
acceptance of their internal experiences, the therapist is encouraged to form a sincere rapport
with the inner most experiences of the patient.
Another feature of these new treatments is to break some of the historical barriers between
behavior therapy and the somewhat less scientifically based approaches (e.g. Psychoanalysis,
Gestalt therapy and Humanistic therapies) trying to integrate some of their fundamental
concepts.
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If, for some, the above elements suggest the emergence of a new wave within the field of CBT,
for others (e.g. Leahy, 2008; Hofmann, 2008) it is neither a paradigm shift, nor do the therapies
have features that confer any greater clinical efficacy. Whilst standard CBT meets the criteria of
Empirically Supported Therapies (ESTs) — that is, therapies that have been proven effective
through randomized controlled trials — for a wide variety of psychological disorders (Butler,
2006), currently we cannot say the same for the approaches seen in third-generation therapies
(Öst, 2008).
Strong supporting evidence that Acceptance and Commitment Therapy (ACT), one of the most
studied third wave approaches, is more effective than Cognitive Therapy is for the most part
lacking and, when present, is derived from studies that have severe limitations, such as a small
sample size or the use of non-clinical samples (Forman, 2007). So the doubt remains whether
the third generation therapies actually represent a “new” wave in CBT. Keeping this is mind; it
may be interesting to reflect on commonalities and differences between the third generation
and the previous two generations.
The first generation’s exposure techniques were one of the most effective tools in the arsenal
of CBT. Even though the underlying mechanism for this has yet to be fully understood
(Steketee, 2002; Rachman, 1991), the rationale behind exposure techniques are reminiscent of
the extinction processes of avoidance responses through the activation of habituation
processes to the stimulus, with a progressive reduction and eventual disappearance of the
physiological and behavioral reactions associated with them so that the patient learns to cope
with the emotions triggered by the feared situations without resorting to avoidance behaviors.
Since experiential avoidance is a central target in third wave approaches, exposure therapy is
undoubtedly still widely used; However, although third generation approaches can be similar to
those of the previous generations, in terms of exposure techniques, the rational and objectives
are different. Patients, in fact, are helped to identify what really matters in their lives and to
engage in actions that are in line with these aims and values.
It is inevitable that such techniques may elicit unpleasant thoughts, emotions and physiological
sensations, resulting in the impulse to avoid the experiential event. Therefore, third generation
approaches are intended to reduce the avoidance behavior and increase the patient’s
behavioral repertoire, however not necessarily extinguishing the internal responses (even
though the process of extinction may well take place), but accepting them for what are without
going against them.
The role attributed to life experiences in helping to create the content of thoughts is a similar
concept in both second and third generations, but then there are radical differences with
respect to the importance attributed to thought content in the creation and maintenance of
psychological disturbances. Starting with the assumption that a stimulus can affect the
emotions of a patient only as a consequence of how that emotion is processed and interpreted
by his cognitive system, cognitive therapies aim to bring about a change in the patient through
the correction of the content of his dysfunctional thoughts; in contrast, third wave therapies
state that an excessive focus on the content of thoughts may contribute to worsening of
symptoms. Leahy (2008) criticizes this position, citing the amount of empirical research
supporting the greater efficacy of cognitive psychotherapy when compared to any other
therapeutic approach. On the other hand, while reflecting on the new elements of the third
generation, Leahy (2008) admits that the techniques which bring about distancing from ones
thoughts through acceptance and mindfulness do not differ significantly from the process of
critical thinking, which is the technique used in the cognitive approach.
In conclusion, standard cognitive therapy, which aims to modify the content of thoughts, may
hinder the patient’s acceptance of internal experiences; the solution to which has been
proposed through the methods and approaches of the third wave. These approaches put
forward the idea of changing the patient’s relationship with their own internal events, a
process that can be integrated into standard CBT (Hayes, 1999, and Segal, 2002).
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Conclusion
Thirty years ago the cognitive behavioral approach to therapy was limited to the treatment of
major depressive disorder and a very limited treatment for some anxiety disorders. Most
practitioners at that time viewed this approach as rather simplistic, but admittedly effective for
a small range of problems. The “deeper” and more “challenging” cases would be the focus for
“depth” therapies of various kinds. Although those “depth” therapies provided little evidence
of any effectiveness, they were seen as addressing the “real underlying problems.”
Psychotherapy has come a long way since then. As we have seen above, the cognitive
behavioral approach to therapy provides an effective treatment modality for the full range of
psychiatric disorders. This approach empowers the clinician to provide effective treatment for
depression, generalized anxiety, panic disorder, obsessive-compulsive disorder, social anxiety
disorder, PTSD, bipolar disorder, schizophrenia, eating disorders, body dysmorphic disorder,
couples problems and family therapy issues. Indeed, where medication is part of the treatment
approach, CBT increases medication compliance, resulting in a better outcome for patients
with severe mental illness. The emergence of case conceptualization and schematic models of
personality disorder has provided the clinician with the tools to help patients with
longstanding, apparently intractable personality disorders.
Although psychodynamic theorists may still argue that CBT does not address the deeper issues,
cognitive behavior therapists argue that CBT does deal with the deeper issues — only, it is done
more rapidly and more effectively. New research that indicates that CBT can be effective with
patients suffering from borderline personality disorder illustrates the power of case
conceptualization within a structured proactive approach. Moreover, the treatment
approaches of CBT are not simply derived from clinical lore and convenient anecdotes. Each
structured treatment modality is supported by significant empirical research demonstrating its
effectiveness.
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Forman, E. M., Herbert, J. D., Moitra, E., Yeomans, P. D., & Geller, P. A. (2007). A randomized
controlled effectiveness trial of acceptance and commitment therapy and cognitive therapy for
anxiety and depression. Behavior Modification, 31, 762-799
Hayes, S. C. (2004). Acceptance and commitment therapy, relational frame theory, and the
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Hofmann, S. G., & Asmundson, G. J. (2008). Acceptance and mindfulness-based therapy: New
wave or old hat? Clinical Psychology Review, 28(1), 2-16.
Leahy, R. L. (2007). Emotion and psychotherapy. Clinical Psychology: Science ad Practice, 14,
351-357.
Leahy, R. L. (2008). A closer look at ACT. The Behavior Therapist, 31(8), 147-150.
Öst, L. G. (2008). Efficacy of the third wave of behavioral therapies: A systematic review and
meta analysis. Behavior Research and Therapy, 46, 295-321.
Segal, Z. V., Williams, J. M., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for
depression: A new approach for preventing relapse. New York: Guilford Press.
Steketee, G. S., & Barlow, D. H. (2002). Obsessive-compulsive disorder. In D. H. Barlow (Ed.),
Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed., pp. 515-
551). New York: Guilford.
Teasdale, J. D. (2003). Mindfulness training and problem formulation. Clinical Psychology:
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Medically reviewed by Scientific Advisory Board — Written by Beppe Micallef-Trigona, MD, MSc
on May 17, 2016
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