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The third wave of cognitive behavioral

therapies: What is new and what is effective?

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 REVIEW

CURRENT
OPINION The third wave of cognitive behavioural therapies:
what is new and what is effective?
Kai G. Kahl a, Lotta Winter a, and Ulrich Schweiger b

Purpose of review
The purpose of this study was to shortly characterize the evolving psychotherapeutic methods summarized
as ‘third wave psychotherapies’ and to review recent research on the therapeutic impact of these methods.
Recent findings
‘Third wave psychotherapies’ comprise a heterogeneous group of treatments, including acceptance and
commitment treatment, behavioural activation, cognitive behavioural analysis system of psychotherapy,
dialectical behavioural therapy, metacognitive therapy, mindfulness-based cognitive therapy and schema
therapy. Several randomized controlled trials, longitudinal case series and pilot studies have been
performed during the past 3–5 years, showing the efficacy and effectiveness of ‘third wave
psychotherapies’.
Summary
The third wave of behavioural psychotherapies is an important arena of modern psychotherapy. It has
added considerably to the spectrum of empirically supported treatments for mental disorders and influenced
research on psychotherapy. The presented methods open up treatment possibilities for patient groups such
as borderline personality disorder, chronic depression or generalized anxiety disorder that had received
only little specific attention in the past. The available evidence now allows considering all third wave
treatments as empirically supported.
Keywords
acceptance and commitment treatment, behavioural activation, cognitive behavioural analysis system of
psychotherapy, dialectical behavioural therapy, metacognitive therapy, mindfulness-based cognitive
therapy, schema therapy

INTRODUCTION for mental disorders – effect sizes are limited,

Behaviour therapy has its roots in the 1950s.
The characteristic feature of this so-called ‘first
wave’ was a focus on classical conditioning and
operant learning. The ‘second wave’ was character-
ized by a focus on information processing. Second
wave (classical) cognitive therapy is at present the
dominant contemporary system of psychotherapy
worldwide. A recent review summarizes more
than 75 clinical trials for cognitive therapy for
unipolar depression that show that this treatment
is superior to placebo, equivalent to other bona fide
treatments and antidepressive pharmacotherapy
[1]. In addition, cognitive therapy seems to be
superior to pharmacotherapy and similar to other
psychotherapies in its effectiveness in reducing the
risk of relapse after discontinuation of treatment [2].
Yet, after more than 45 years of experience with
cognitive therapy, there is also a growing awareness
of its limitations: first – similarly to other treatments
leaving room for improvement; second, treatments
are not universally found acceptable by their users;
and third, data are missing that support the neces-
sity of interventions aimed at a content-oriented
cognitive change which are core elements of classi-
cal cognitive therapy. A review found little evidence
that specific content-oriented cognitive interven-
tions such as challenging dysfunctional thoughts
significantly increase the effectiveness of cognitive
a
Department of Psychiatry, Social Psychiatry and Psychotherapy, Hann-
over Medical School, Hannover and bDepartment of Psychiatry and
Psychotherapy, University of Lübeck, Lübeck, Germany
Correspondence to Kai G. Kahl, Department of Psychiatry, Social
Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neu-
berg-Str. 1, 30625 Hannover, Germany. Tel: +49 511 532 2495; fax:
+49 511 532 8573; e-mail: kahl.kai@mh-hannover.de
Curr Opin Psychiatry 2012, 25:522–528
DOI:10.1097/YCO.0b013e328358e531

www.co-psychiatry.com Volume 25
Number 6
November 2012

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

KEY POINTS

Third wave or new wave psychotherapy refers to a
heterogeneous spectrum of psychotherapy methods that
have proven to be effective, in particular in patients
who were formerly seen as difficult to treat.

Third wave psychotherapies have expanded the
methodological and technical spectrum and are still
influencing the development of psychotherapy.

Several randomized controlled trials have been
performed during the last years, allowing it to be
considered that third wave psychotherapies are
empirically supported.

There are no studies supporting the assumption that
either psychotherapy (third wave versus second wave)
or classical cognitive behavioural therapy (CBT) is
superior over the other. However, attrition rates are
different between psychotherapies, with a trend for
better acceptance of third wave treatments in particular
patient groups.
therapy [3]. A component analysis indicates that
the efficacy of cognitive therapy depends critically
on behavioural activation as only intervention
[4,5]. The ‘third wave’ of behavioural therapies
is characterized by themes new to behavioural
psychotherapies: metacognition, cognitive fusion,
emotions, acceptance, mindfulness, dialectics,
spirituality and therapeutic relationship. The tech-
niques used in third wave methods are quite hetero-
geneous. Commonalities are the abandonment or
cautious use of content-oriented cognitive interven-
tions and the use of skills deficit models to delineate
the core maintaining mechanisms of the addressed
disorders. A further aspect is a renaissance of first
wave principles such as operant conditioning [6].
REVIEW
The present review focuses on relevant randomized
controlled studies after 2007, selected uncontrolled
studies and selected studies relevant to basic under-
lying concepts. A meta-analysis of the evidence until
2007 was published by Ost [7].
Acceptance and commitment treatment
Acceptance and commitment therapy (ACT) [8] is a
method of behavioural therapy that is based on
functional contextualism and the relational frame
theory. It posits the following psychopathological
processes as central to mental disorders: (1) cogni-
tive fusion; (2) experiential avoidance; (3) attach-
ment to a verbally conceptualized self and a verbally
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The third wave of cognitive behavioural therapies Kahl et al.
conceptualized past; (4) lack of values or confusion
of goals with values; and (5) absence of committed
behaviour that moves in the direction of chosen
values. The treatment contains psychoeducation
about key mechanisms, exercises in mindfulness
and cognitive defusion. The value orientation of
the patient is elicited and discussed, and patients
are supported in value-driven behaviour in contrast
to behaviour driven by emotional or experiential
avoidance [9].
There are several randomized controlled trials
(RCTs) to test the efficacy of ACT in heterogeneous
clinical conditions. ACT was associated with a
reduction of depressive symptoms in men and
women with subclinical depression [10 ]. ACT
&
was superior to progressive relaxation training in
reducing symptoms of obsessive compulsive dis-
order in 79 patients [11]. In substance use disorders,
ACT-based psychotherapy combined with bupro-
pione significantly improved smoking cessation
compared with bupropione alone (quit rates:
31.6 versus 17.5%) [12]. Interestingly, ACT has also
been shown to reduce shame in patients with
substance use disorders after a 4-month follow-up
period, associated with reduced substance use [13].
In 116 patients with nonmalignant pain, an 8-week
group therapy was as effective as cognitive beha-
vioural therapy in reducing pain interference and
pain-related mood symptoms [14]. An RCT in ACT
also addressed nonclinical populations. ACT has
been tested versus psychoeducation to promote
&
physical activity in adults [15 ]. Healthy adult
persons randomized to ACT were more likely
to improve their physical activity, pointing to
short-term effects of ACT in lifestyle changes. ACT
has been shown to be effective in reducing levels
of stress and burnout in Swedish social workers
(n ¼ 106) [16].
Also, several longitudinal studies, case series and
pilot studies were published, pointing to usefulness
of ACT in pain [17], eating disorders [18,19],
marijuana dependence [20], methadone reduction
[21], generalized anxiety disorder [22] and affective
symptoms in psychotic disorders [23].
Behavioural activation
Behavioural activation is a third wave method for
treating depression and other mental disorders.
It emerged from studies analysing the necessary
components of classical cognitive therapy [4,5,24].
These studies showed that behavioural activation
is a stand-alone component that has a similar or
superior efficacy compared with cognitive therapy.
Behavioural activation has evolved from a long
behavioural tradition seeking to increase positive
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 Clinical therapeutics
reinforcement by scheduling appropriate patient
behaviours and thus achieving antidepressant
action. Important changes compared with earlier
versions are a shift from ‘pleasant’ activities to
value-driven activities, a shift strongly influenced
by ACT and the adoption of the concept of ‘opposite
action’ from dialectical behavioural therapy (DBT)
[25]. The goal is to bring the patient into contact
with diverse, stable and valued sources of positive
reinforcement. Behavioural activation encompasses
psychoeducation, activity monitoring, scheduling
of antidepressant activities and troubleshooting.
The follow-up of an RCT showed that beha-
vioural activation and cognitive therapy had similar
enduring effects, which were as efficacious as con-
tinuous treatment with medications [4]. An RCT
combining behavioural activation strategies with
cessation treatment for smokers with elevated
depressive symptoms not only showed that this
treatment leads to higher rates of abstinence than
standard smoking cessation treatment but also that
depressive symptoms were lower during the follow-
up period [26]. An RCT in geriatric psychiatric
inpatients showed a greater reduction in depressive
symptoms with behavioural activation than in a
control condition [27]. An RCT in female patients
with breast cancer and major depression compared
behavioural activation and problem-solving therapy
&
[28 ]. Large effect sizes were observed in both treat-
ments with similar rates of remission and response.
A small pilot study points to good effectiveness of
behavioural activation also in atypical depression.
Cognitive behavioural analysis system of
psychotherapy
The cognitive behavioural analysis system of
psychotherapy (CBASP) was specifically developed
for the treatment of patients with chronic depres-
sion. CBASP assumes that skills deficits in the area of
operational thinking lead to a failure of interperso-
nal behaviour and subsequent depression [29,30].
The method comprises three therapeutic tech-
niques: situational analysis, interpersonal discrimi-
nation exercise and consequating strategies, all
with the aim of teaching operational thinking
and interpersonal behaviour driven by empathy
and personal values.
The fundamental assumption of a preoperative
cognitive style in chronic depressed patients is
supported by one study [31], demonstrating
that preoperative thinking is more pronounced in
patients with chronic depression than in patients
with episodic depression and healthy volunteers.
In the Research Evaluating the Value of Aug-
menting Medication with Psychotherapy study,
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an RCT with over 800 depressed patients, CBASP,
brief supportive psychotherapy and optimized
pharmacotherapy were equivalent as augmentation
strategies [32]. The study has been criticized because
of potential methodological problems. In particular,
only those patients were included who had
consented to a pharmacotherapy-only study and
had not achieved remission; patients received only
a mean of 12.7 CBASP sessions, and patients with
substance-related disorder were enrolled if they
did not require detoxification. This may hint at
insufficient motivation or inadequate implementa-
tion of the intervention. However, social problem
solving was significantly improved in CBASP treated
patients and predicted a change in depressive
symptoms over time [33].
Dialectical behavioural therapy
Dialectical behavioural therapy was originally
developed for parasuicidal patients with borderline
personality disorder (BPD) [34]. Modifications
have now been developed for substance abuse and
eating disorders. DBT assumes that skills deficits in
the area of emotion regulation are at the centre of
these disorders. Accordingly, DBT teaches a broad
spectrum of skills in the areas of mindfulness,
distress tolerance, emotion regulation and inter-
personal effectiveness [35,36].
The skills deficit model underlying DBT was
supported in a study showing that the extent of
skills use mediated the effects of DBT and led to
decreased suicidal behaviour, decreased depression
and better anger control [37]. DBT has been shown
to result in a positive therapeutic relationship and to
impact substantially intrapsychic and personality
factors, not merely reducing symptoms [38].
An RCT showed comparable improvements
in suicidal behaviour, BPD psychopathology and
healthcare utilization when DBT was contrasted
with a general psychiatric management performed
by community experts delivering psychodynamic
therapy and symptom-targeted pharmacotherapy
[39]. Another RCT compared DBT with standard
group therapy, demonstrating greater clinical
improvements and lower dropout rates [40].
Metacognitive therapy
Metacognitive therapy (MCT) [23] evolved from
classical cognitive therapy. Metacognition is the
aspect of cognition that controls mental processes
and thinking. Knowledge about metacognition
originated in research on learning and decision-
making in children. MCT posits that the cognitive
attentional syndrome, a psychopathological state
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consisting of repetitive cognitive processes such
as worrying, rumination, dysfunctional threat
monitoring and dysfunctional cognitive and beha-
vioural copying, is at the core of depressive and
anxiety disorders. MCT abstains from content-
oriented interventions, uses attention training tech-
niques to develop skills in cognitive flexibility,
teaches a special form of mindfulness (detached
mindfulness) and guides cognitive and behavioural
experiments to change metacognition.
The underlying concept of MCT is that meta-
cognitions must change in order for psychological
treatment to be effective. This assumption was
supported by a study [41] showing that change in
metacognitions was a better predictor of outcome
than change in cognitions in patients with obsessive
compulsive disorder treated with exposure or
response prevention techniques.
An RCT including 126 patients compared MCT,
intolerance-of- uncertainty therapy and a waiting
list in the treatment of general anxiety disorder
[42]. MCT in this study produced significantly better
outcome on most outcome variables; remission
rates were similar in both treatments. A smaller
RCT including 20 patients compared MCT with
relaxation equally in the treatment of general
anxiety disorder [43]. MCT was superior both
at posttreatment and at 12-month follow-up. An
uncontrolled trial investigating MCT in the manage-
ment of treatment-resistant depression showed high
&
remission rates [44 ].
Mindfulness-based cognitive therapy
Mindfulness-based cognitive therapy (MBCT) arose
from experiences in the application of Buddhist
meditation techniques in medicine [45]. It was
specifically developed to reduce the number of
relapses in patients with major depression. MBCT
uses psychoeducation and encourages the patients
to practice mindfulness meditation. A core goal is
to develop metacognitive awareness, which is the
ability to experience cognitions and emotions as
mental events that pass through the mind and
may or may not be related to external reality.
The focus is not to change ‘dysfunctional’ thoughts
but to learn to experience them as internal events
separated from the self [46].
An RCT compared rates of relapse in remitted
depressed patients, treated with either antidepress-
ant maintenance treatment, placebo or MBCT only.
Relapse rates were similar in both treatment groups
&
and lower than in placebo [47 ]. Another RCT
comparing only antidepressant maintenance with
MBCT found a trend towards lower relapse rates
with MBCT [48]. An RCT comparing MBCT in
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The third wave of cognitive behavioural therapies Kahl et al.
recovered patients with major depression with
treatment as usual found better outcome with
MBCT, i.e. lower relapse rates [49]. In contrast to
the earlier focus on relapse prevention, recent
studies examined the impact of MBCT on current
and treatment-resistant depression, and on other
psychiatric disorders such as substance use dis-
orders. In a current nonmelancholic depressive
episode, MBCT was similarly effective to cognitive
therapy [50]. In the treatment of chronic depres-
sion, MBCT was superior in response rates to treat-
ment as usual [51]. A modified programme based
on MBCT strategies was tested in patients with
substance use disorders after intensive stabilization;
most of them were diagnosed with alcohol depend-
ence [52]. One hundred and sixty-eight study
participants were randomized to either 8 weekly
sessions of mindfulness-based relapse prevention
(MBRP) or treatment as usual. MBRP was effective
in reducing the days with alcohol or drug use
during the 4-month follow-up period. This effect
was mediated by altered emotional and behavioural
responses to depressive symptoms in the MBRP
group.
Schema therapy
Schema therapy was originally developed for the
treatment of personality disorders and other chronic
mental disorders. Schema therapy is derived from
classical cognitive therapy; yet, compared with
cognitive therapy, it has substantially elaborated
the concept of schemata and modes. It comprises
a large spectrum of techniques to address emotions,
cognitions and behaviour in the present life of the
patient, within therapy and related to events and
experiences in the past. Schema therapy is inte-
grative in the sense that it uses emotion activation
techniques originating in Gestalt and Psychodrama;
yet, it is strictly behavioural in the models com-
municated to the patient. One of the dominant
skills trained in schema therapy is to recognize
the present dysfunctional modes of functioning,
such as the detached protector mode, and to
have behaviour guided by the healthy adult mode
[53].
An RCT comparing schema therapy with
transference focused psychotherapy in borderline
personality disorder showed better cost-effective-
ness of schema therapy [54]. An RCT including
32 patients with borderline personality disorder
compared schema therapy group with treatment
as usual [55]. Remission rates in schema therapy
were clearly superior. An RCT comparing schema
therapy with and without telephonic crisis support
in patients with borderline personality found high
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 Clinical therapeutics
remission rates but no additional benefit of the crisis
support [56].
SUMMARY AND CONCLUSION
Ost [7] in 2008 concluded that ‘no third wave
therapy fulfils the criteria for empirically supported
treatments’. Yet, if we apply the criterion that a
psychotherapy method should be supported by at
least two RCTs of sufficient size and quality showing
superiority to waiting list or treatment as usual or
similar effects to another bona fide treatment and
that there should be additional evidence supporting
the method and no evidence pointing to relevant
harmful effects [57], the present review shows that
all third wave therapies with the exception of CBASP
fulfil these minimal entry criteria. And it is highly
probable that, with the publication of the yet
unpublished data, CBASP will also follow. So, there
is little doubt that the presented third wave methods
are principally efficacious.
The next question is: are third wave therapies
superior to classical cognitive therapy? This ques-
tion is difficult to answer, as extensive research
shows that superiority among bona fide treatments
is difficult or impossible to establish [58]. This
is related to methodological and time constraints
and should not be translated to ‘it doesn’t matter
what I do as long as the therapeutic alliance is good’
and should not lead to a cynical attitude towards
the necessity of methodological innovation in
psychotherapy (‘old wine in new bottle’). Certainly,
it can be debated whether on a technical level
differences of similarities to classical cognitive
therapy prevail [59].
Beyond the debate about effect sizes, the follow-
ing aspects merit attention when reflecting on the
third wave.
How close are the methods linked to science
in related areas? Many aspects of the third wave
are based on basic research in psychological mech-
anisms and reflect its current status better than
classical cognitive therapy. For example, current
research in the importance of metacognition,
thought and emotion suppression [60], worry,
rumination or experiential avoidance [61] has
deeply influenced MCT, ACT, MBCT, DBT and
schema therapy. All third wave methods have
strong roots in learning theory. Particularly, ACT
and behavioural activation have a strong emphasis
on the topic of values, goals and behaviour. CBASP
is strongly influenced by developmental psychology
and interpersonal theory.
How well are the new methods received by the
patients? There is little research on this subject. Yet,
indirect conclusions can be drawn from the fact that
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attrition rates in ‘difficult’ patient groups such as
borderline personality disorder are lower in DBT
and schema therapy than in traditional psycho-
therapy and are considerably lower in MBCT than
in pharmacotherapy. Optimistically stated, it can be
said that the third wave has opened up psycho-
therapy as a possibility for groups that before had
little access to psychotherapy.
The dissemination of new psychotherapy
methods lives on the subjective experience of
the involved psychotherapist to perform better or
to deal better with situations that seemed insur-
mountable before. The development of therapist
preference for a method is certainly subject to bias.
The equation that the preferred methods are the
best methods must be critically examined. Still,
the perspective of therapists having hands-on
experience with several methods of psychotherapy
merits scientific attention.
What are the limitations of the third wave
methods? Despite the impressive increment of
knowledge in the last years, the third wave methods
still lag behind classical cognitive therapy in the
extent of its evidence base. To name a few important
gaps: there is no study in the application of ACT
to patients with severe depression, and there is
no substantial evidence for schema therapy out-
side the treatment of patients with borderline
personality disorder. A second successful RCT in
CBASP is missing.
Conclusion
The third wave of behavioural psychotherapies is an
important arena of modern psychotherapy develop-
ment. It has added considerably to the spectrum of
empirically supported treatments for mental dis-
orders. The presented methods include a diversity
of new techniques and open up possibilities for
patient groups such as borderline personality dis-
order, chronic depression or generalized anxiety
disorder that had received only little specific atten-
tion in the past. The available evidence now allows
all third wave treatments to be considered as empiri-
cally supported. Still, compared with classical
cognitive therapy, there is an enormous deficit in
the amount of evidence.
Acknowledgements
None.
Conflicts of interest
Kai G. Kahl received speaker honoraria from EliLilly,
BMS, Servier, Lundbeck and Janssen-Cilag. Ulrich
Schweiger and Lotta Winter report no conflict of interest.
Volume 25
Number 6
November 2012

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Volume 25
Number 6
November 2012