The Third Wave of CBT
The approaches of the first two generations of Behavioral Therapy (BT) share the assumption that certain cognitions, emotions and physiological states lead to dysfunctional behavior and, therefore, therapeutic intervention is aimed at eliminating, or at least reducing, these problematic internal events. Third wave therapies are expanding their targets from the mere reduction of symptoms to the development of skills aimed at significantly improving the quality and quantity of activity in which the patient finds value. Even with seriously ill patients, the new behavioral therapies emphasize empowerment and increase in skills and behavioral repertoires that may be used in many contexts (Hayes, 2004).
The emphasis on building healthy behavioral skills, finds its rationale in the assumption that the processes which the patient fights against constantly (judging and attempting to control their internal experiences) are the same as those experienced by the therapist (Hayes, 2004); resulting in the fact that the methods and techniques of these therapies are suitable as much for the therapists as they are for the patients. In efforts made by the patient to increase acceptance of their internal experiences, the therapist is encouraged to form a sincere rapport with the inner most experiences of the patient.
Another feature of these new treatments is to break some of the historical barriers between behavior therapy and the somewhat less scientifically based approaches (e.g. Psychoanalysis, Gestalt therapy and Humanistic therapies) trying to integrate some of their fundamental concepts.
If, for some, the above elements suggest the emergence of a new wave within the field of CBT, for others (e.g. Leahy, 2008; Hofmann, 2008) it is neither a paradigm shift, nor do the therapies have features that confer any greater clinical efficacy. Whilst standard CBT meets the criteria of Empirically Supported Therapies (ESTs) — that is, therapies that have been proven effective through randomized controlled trials — for a wide variety of psychological disorders (Butler, 2006), currently we cannot say the same for the approaches seen in third-generation therapies (Öst, 2008).
Strong supporting evidence that Acceptance and Commitment Therapy (ACT), one of the most studied third wave approaches, is more effective than Cognitive Therapy is for the most part lacking and, when present, is derived from studies that have severe limitations, such as a small sample size or the use of non-clinical samples (Forman, 2007). So the doubt remains whether the third generation therapies actually represent a “new” wave in CBT. Keeping this is mind; it may be interesting to reflect on commonalities and differences between the third generation and the previous two generations.
The first generation’s exposure techniques were one of the most effective tools in the arsenal of CBT. Even though the underlying mechanism for this has yet to be fully understood (Steketee, 2002; Rachman, 1991), the rationale behind exposure techniques are reminiscent of the extinction processes of avoidance responses through the activation of habituation processes to the stimulus, with a progressive reduction and eventual disappearance of the physiological and behavioral reactions associated with them so that the patient learns to cope with the emotions triggered by the feared situations without resorting to avoidance behaviors.
Since experiential avoidance is a central target in third wave approaches, exposure therapy is undoubtedly still widely used; However, although third generation approaches can be similar to those of the previous generations, in terms of exposure techniques, the rational and objectives are different. Patients, in fact, are helped to identify what really matters in their lives and to engage in actions that are in line with these aims and values.
It is inevitable that such techniques may elicit unpleasant thoughts, emotions and physiological sensations, resulting in the impulse to avoid the experiential event. Therefore, third generation approaches are intended to reduce the avoidance behavior and increase the patient’s behavioral repertoire, however not necessarily extinguishing the internal responses (even though the process of extinction may well take place), but accepting them for what are without going against them.