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

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 And it is highly probable that, with the publication of the yet unpublished data, CBASP will also follow.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 question 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 following 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 mechanisms 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 attrition rates in 'difficult' patient groups such as borderline personality disorder are lower in DBT and schema therapy than in traditional psychotherapy and are considerably lower in MBCT than in pharmacotherapy. Optimistically stated, it can be said that the third wave has opened up psychotherapy 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 insurmountable 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 outside the treatment of patients with borderline personality disorder. A second successful RCT in CBASP is missing.


The third wave of behavioural psychotherapies is an important arena of modern psychotherapy development. It has added considerably to the spectrum of empirically supported treatments for mental disorders. The presented methods include a diversity of new techniques and open up 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 all third wave treatments to be considered as empirically supported. Still, compared with classical cognitive therapy, there is an enormous deficit in the amount of evidence.