The Third Wave of Cognitive Behavioural Therapies

What Is New and What Is Effective?

Kai G. Kahl; Lotta Winter; Ulrich Schweiger


Curr Opin Psychiatry. 2012;25(6):522-528. 

In This Article

Abstract and Introduction


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.


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 characterized 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 for mental disorders – effect sizes are limited, leaving room for improvement; second, treatments are not universally found acceptable by their users; and third, data are missing that support the necessity of interventions aimed at a content-oriented cognitive change which are core elements of classical cognitive therapy. A review found little evidence that specific content-oriented cognitive interventions such as challenging dysfunctional thoughts significantly increase the effectiveness of cognitive 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 techniques used in third wave methods are quite heterogeneous. Commonalities are the abandonment or cautious use of content-oriented cognitive interventions 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]