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


The present review focuses on relevant randomized controlled studies after 2007, selected uncontrolled studies and selected studies relevant to basic underlying 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) cognitive fusion; (2) experiential avoidance; (3) attachment to a verbally conceptualized self and a verbally 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 disorder in 79 patients.[11] In substance use disorders, ACT-based psychotherapy combined with bupropione 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 behavioural 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 = 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 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 behavioural activation and cognitive therapy had similar enduring effects, which were as efficacious as continuous 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 treatments 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 depression. CBASP assumes that skills deficits in the area of operational thinking lead to a failure of interpersonal behaviour and subsequent depression.[29,30] The method comprises three therapeutic techniques: situational analysis, interpersonal discrimination 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 Augmenting Medication with Psychotherapy study, 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 implementation 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 interpersonal 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 consisting of repetitive cognitive processes such as worrying, rumination, dysfunctional threat monitoring and dysfunctional cognitive and behavioural copying, is at the core of depressive and anxiety disorders. MCT abstains from content-oriented interventions, uses attention training techniques 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 metacognitions 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 management 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 antidepressant 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 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 disorders. In a current nonmelancholic depressive episode, MBCT was similarly effective to cognitive therapy.[50] In the treatment of chronic depression, MBCT was superior in response rates to treatment 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 dependence.[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 integrative in the sense that it uses emotion activation techniques originating in Gestalt and Psychodrama; yet, it is strictly behavioural in the models communicated 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-effectiveness 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 remission rates but no additional benefit of the crisis support.[56]