Criminal Behaviour and Mental Health

20: 251–256 (2010)

Published online in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/cbm.772

Editorial
The ‘third wave’ of cognitive-
behavioural therapy and
forensic practice

KEVIN HOWELLS, Institute of Mental Health and Division of Psychiatry,

Nottingham University; Peaks Academic and Research Unit, Rampton
Hospital, UK

It is clearly desirable that clinical practice in the forensic field is consistent with
theory and research in the broader fields of clinical psychology and psychiatry.
This is not to say that forensic practice should necessarily passively follow a path
already trodden by non-forensic practitioners and theorists. Indeed, it could be
argued that forensic models have introduced new concepts and methods that
have influenced the broader clinical field, or, in some cases, should have such an
influence. Two examples of actual or potential forensic influence on the clinical
field are the so-called What Works (Hollin and Palmer, 2006) movement in
offender rehabilitation and Ward’s Good Lives model (Ward and Stewart, 2003).
The disciplined, highly structured approach to treatment and rehabilitation pro-
vided by What Works, derived largely from correctional programmes, has underly-
ing principles that are relevant to a broader range of clinical interventions. The
constructs of programme responsivity, treatment integrity, and risk- and needs-
based services as predictors of outcome, for example, could be applied in non-
forensic areas of practice in the mental health field. Equally, the notion that
treatment should be based on, or at least substantially include, assisting the
person to construct a ‘good life’ and a positive identity rather than focus exclu-
sively on eliminating problems and abnormalities has relevance beyond the foren-
sic field. The detailed analysis and theoretical exposition of good lives provided
by Ward is of broad relevance to many mental health therapists.
But, are there new developments in the broader clinical field of which forensic
practitioners need to be cognisant? Focused offending treatment and rehabilita-
tion programmes, for example for sex offending or violence, have become estab-
lished across many jurisdictions in the world and are widely delivered in forensic
mental health as well as criminal justice services. In general, these programmes

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have been strongly cognitive-behavioural in theoretical orientation, reflecting the

conclusion of many outcome studies that cognitive-behavioural interventions
have been demonstrated to be effective, at least when the outcome being addressed
is that of recidivism (Hollin and Palmer, 2006). Are applications of the cognitive-
behavioural model in the forensic field up to date?

Expanding our notions of cognitive-behavioural treatment

It is important to acknowledge that ideas about effective therapies are not set in
stone. It has been suggested that cognitive-behavioural treatment has had three
phases: early behavioural treatments (for example, exposure-based interventions
for phobias), cognitive–focused therapy (for example, cognitive therapy for depres-
sion) and, more recently, ‘third-wave’ treatments (Hayes et al., 2004), strongly
influenced by eastern philosophical and contemplative traditions, particularly
Buddhism. Among the particular third-wave methods that have been imple-
mented are ‘acceptance and commitment therapy’ (Hayes et al., 2004) and ‘mind-
fulness’ training (Crane, 2009). Such treatments have become established within
mainstream cognitive-behavioural therapy (CBT) and feature in contemporary
textbooks of evidence-based practice (for example, Kazantzis et al, 2010), with
rapid development of treatment manuals (Crane, 2009) and self-help materials
and exercises. More recently, compassion-based interventions, again strongly
influenced by Buddhism, have also received attention, though the empirical lit-
erature relating to therapeutic impacts is less substantial.

Mindfulness

Mindfulness training has become the most influential third-wave treatment

approach, largely, no doubt, because of the growing body of outcome literature,
including randomised controlled trials, indicating an impact on recurrent depres-
sion (Dimidjian et al., 2010), general stress and a range of psychosomatic condi-
tions (Singh et al., 2008).
Mindfulness practices have a long history, probably of more than 2500 years,
but have come under significant scientific and clinical scrutiny in only the last
15 years. Mindfulness typically involves training the mind to observe the present
moment and the stream of consciousness in a non-judgemental way, with ‘bare
attention’. The identification of the self with the contents of consciousness, par-
ticularly with sequences of thought relating to the past or the future, is weakened
(‘decentring’ pathogenic cognition). A common, though not the only, method
for focusing the mind has been meditation on the breath (Crane, 2009).
It is not difficult to see how such a method might be very relevant to someone
struggling with overpowering depressive thoughts, but how might it be relevant
to the problems of patients in forensic mental health services? It has been

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 third-wave CBT 253

suggested (Howells et al., 2010) that three areas of criminogenic and clinical need
can be viewed as reflecting poor mindfulness and is therefore potentially remedi-
able through mindfulness training. These are poor affective self-regulation (Day,
2009), the related problem of anger control (Wright et al., 2009) and impulsivity.
Such problems appear to be severe in offenders with personality disorder, particu-
larly those with borderline personality disorder.
There is increasing research attention to the impact of mindfulness on emotion
processes and affective self-regulation (Davidson, 2010). Davidson suggests: ‘affec-
tive processes are a key target of contemplative interventions. The long-term
consequences of most contemplative traditions include a transformation of trait
affect’ (p. 10). There is also evidence that trait mindfulness is correlated with the
‘big five’ personality dimensions, notably negatively with neuroticism (estimated
mean true score, p = −0.58) and negative affect (p = −0.51), and positively with
conscientiousness (p = 0.44) and positive affect (p = 0.41) (Giluk, 2009). The asso-
ciation with conscientiousness is interpreted by Giluk (2009) as possibly reflecting
concern for others and empathy.
Similarly, rumination, defined as ‘repetitive, uncontrollable thoughts about
negative internal or external experiences’, has been shown to relate reliably to
anger, hostility and aggression (Borders et al., 2010). Given the focus in mindful-
ness training on improving awareness and control of such thoughts, it has obvious
potential as a therapeutic intervention, with some support from experimental
studies in normal populations (Borders et al., 2010).

What is the evidence for mindfulness effects?

There have been several reviews of the effectiveness of mindfulness training.

Dimidjian et al. (2010) review the evidence that mindfulness, in relation to treat-
ment of recurrent depression, has solid support in terms of both the underlying
theoretical model and controlled studies of treatment outcome. Mindfulness-
based cognitive therapy (MBCT) has been identified as an effective treatment
for recurrent depression by the National Institute of Clinical Excellence in the
United Kingdom (Kuyken et al., 2008). Given that the positive evidence has
been predominantly in relation to depression, and stress-related conditions and
disorders, it is reasonable to conclude that the potential of mindfulness training
is in relation to improving negative affective states, the latter being a factor
contributing to criminogenic and clinical problems in forensic populations (Day,
2009).
Thus, mindfulness methods have high face validity in forensic clinical prac-
tice, but it has to be said that outcome evidence with forensic patients is, as yet,
thin. Early outcome studies have been promising but typically consist of small-
scale controlled single-case studies (see review by Singh et al., 2008) or larger
studies lacking rigorous control groups (Samuelson et al., 2007).

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254 Howells

There may be particular difficulties in implementing mindfulness and similar

interventions in forensic settings, not least the unknown cultural acceptability
of methods (for example, sitting meditatively and in silence) that may be per-
ceived as unfamiliar, esoteric and even alien by some. Mindfulness programmes
are, however, beginning to be delivered, and apparently accepted, on a large scale
in prisons in the USA (Samuelson et al., 2007). In prisons in England and Wales,
mindfulness forms part of Buddhist chaplaincy in at least 120 penal establish-
ments (Angulimala, 2010). Evaluation of well-established mindfulness pro-
grammes is an obvious first task, before setting up new programmes for research
purposes.
Third-wave approaches have not gone without criticism and even stern rebuke.
In the foreword to a comprehensive text describing developments in contempo-
rary CBT, Dattilio (2010), for example, suggests that ‘although there is some
empirical evidence to support these approaches, some are under scrutiny because
of the failure to fulfil the requirement of empirically supported treatments’. Addi-
tionally, it is unclear whether many of the third-wave treatments can be consid-
ered independent from the basic genre of CBT’. Although there have been
attempts to provide innovative contributions, many such treatments ‘simply rest
on traditional models and wrap them in new paper’ (p. xii). Third-wave practi-
tioners have tried to distinguish their approach from conventional CBT and this
has provoked spirited attempts to identify areas of commonality (e.g. a common
focus on emotion regulation) and of substantial difference.
One of the problems in evaluating outcomes of third-wave therapies has been
the unfortunate concatenation of very different therapies under the rubric ‘third
wave’. Ost’s (2008) systematic review, for example, includes functional analytic
psychotherapy, integral behavioural couple therapy, dialectical behaviour therapy
and other therapies along with those more generally acknowledged to be third
wave such as acceptance and commitment therapy, while not including mindful-
ness training.
There are two features of mindfulness as an intervention that distinguish it
from traditional clinical practice. Firstly, although mindfulness training is often
delivered in clinical or similar settings, the intervention itself is the product of a
philosophical and psychological system (Buddhism) concerned not primarily with
treatments for disorders per se, but with the enlightenment or psychological lib-
eration of the ordinary person (Singh et al., 2008). In this sense, mindfulness has
some similarity to developments in positive psychology. Secondly, consistent with
this, but also comparable with psychoanalytic approaches, it is seen as important
that the therapist has personally undertaken mindfulness training. Dimidjian
et al. (2010), for example, suggest, ‘perhaps the most important principle of
MBCT is the instructor’s own personal mindfulness practice . . . it is important
for instructors to draw upon their own experience in the development of the very
same skills of awareness and compassion’ (p. 316). It is apparent that many mind-
fulness therapists have a long-term personal mindfulness practice, though the

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 third-wave CBT 255

extent to which it is embedded in a broader philosophical or spiritual belief

system on their part is unknown. This may raise the difficult and unresolved
question of where the boundary between a clinical therapeutic method and
spiritual or religious practice might lie. Would mindfulness training in a prison
or forensic mental health service be the province of a mental health professional,
the chaplain or both?
In summary, there is a demonstrable need for forensic practitioners to be aware
of the rapid progress and accumulating evidence for third-wave therapies, particu-
larly mindfulness training, in general clinical psychology and psychiatry. Mind-
fulness appears to meet the very clinical and criminogenic needs that have been
identified in forensic populations, but for which therapeutic remedies are in short
supply. The scientific task, however, of formally evaluating effectiveness of such
methods has barely begun.

References
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Crane R (2009) Mindfulness-Based Cognitive Therapy. London: Routledge.
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Theories in Clinical Practice. New York: Guilford pp. xv–xvii.
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Wright S, Day A, Howells K (2009) Mindfulness and the treatment of anger problems. Aggression
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Address correspondence to: Professor Kevin Howells, Clair Chilvers Building,

Rampton Hospital, Retford, Nottinghamshire DN22 OPD, UK. Email: Kevin.
howells@nottingham.ac.uk

Copyright © 2010 John Wiley & Sons, Ltd 20: 251–256 (2010)
DOI: 10.1002/cbm
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