Thursday, March 3, 2011

Investigating the Similarities and Differences Between Practitioners of Second- and Third-Wave Cognitive Behavioral Therapies

In 2004, Dr. Steven Hayes published an influential paper in which he coined the term "third wave." Third wave refers to the mindfulness and acceptance-based cognitive behavioral therapies we focus on in Scientific Mindfulness: Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT), and Mindfulness-Based Cognitive Therapy (MBCT), among others.

In calling these third wave treatments, Dr. Hayes distinguished them from the first wave of treatments that came out of behaviorism, and from the second wave of therapies that came out of cognitive therapy. Traditional cognitive behavioral therapy (CBT), which focuses on changing maladaptive thoughts, is a second wave treatment. The mindfulness and acceptance-based treatments of the third wave differ from the second wave, according to Dr. Hayes, in their focus on changing how people relate to thinking, not the thoughts themselves. (You can download a copy of this seminal article at the bottom of this post.)

A group of researchers affiliated with Brown University took some data from a larger study to examine similarities and differences between second and third wave therapists. Out of a sample of 176 clinicians who completed an Internet survey, 55 identified as second wave and 33 identified as third wave. The terms second and third wave weren't actually used in the Internet survey: rather, therapists who identified as "cognitive or cognitive behavioral" (i.e., second wave) or "acceptance-based behavioral/cognitive" (i.e., third wave) were included in the two categories.

In general, the researchers found that second and third wavers are more similar than different. For example, both were equally likely to endorse using social skills training and homework. The main differences the authors found were related to techniques and treatment strategies. Second wavers were more likely to use traditional cognitive techniques such as cognitive restructuring and relaxation training; by contrast, third wavers were--as you might imagine--more likely to use mindfulness and acceptance techniques.

Curiously, third wavers were also more likely to report using existential/humanistic and family systems techniques. The authors offers explanations for these findings. For one, they suggest the emphasis in values clarification in ACT may explain the endorsement of existential/humanistic techniques. This is a reasonable assumption but, by no means, an clear-cut interpretation. What seems a little more far afield is the authors' suggestion that the endorsement of family systems techniques reflects a greater inclusiveness in the use of techniques by third wavers. Again, this assumption is not unreasonable, but it seems like a stretch in the absence of any additional data. That said, I don't know how to explain these findings either!

What I found most interesting is that third wavers reported greater use of exposure. Exposure is a decades old behavioral intervention that has been widely successful in treating anxiety disorders (e.g., anxiety, phobias, obsessive-compulsive disorder, and posttraumatic stress disorder). In my view, exposure is an extremely useful intervention when appropriate applied. As it's also been incorporated into traditional CBT and interpreted according to cognitive models, I find it really interesting that second wavers are significant less likely to use exposure than third wavers because it is frequently a component of empirically-supported CBT treatments for anxiety disorders.

The authors conclude both second and third wavers emphasize evidence-based practice. Where they differ is that, although third wavers use both first and second wave interventions, they are less likely to use traditional cognitive techniques (e.g., cognitive restructuring). One important potential bias the authors note is that, as they recruited from an ACT listserv, among other listservs, ACT therapists may be over-represented in their sample compared to other third wave therapies such as DBT and MBCT. Consequently, the results may be more reflective of ACT therapists than to the broader community of third wave therapists.

The full citations are below. Only members of ACBS can download the main article I covered. However, everyone can click on the second citation to download a copy of Dr. Hayes seminal 2004 article:

Brown, L.A., Gaudiano, B.A., & Miller, I.W., (2011). Investigating the Similarities and Differences Between Practitioners of Second- and Third-Wave Cognitive Behavioral Therapies. Behavior Modification, 35(2), 187-200.

Hayes, S.C. (2004). Acceptance and Commitment Therapy, Relational Frame Theory, and the Third Wave of Behavior Therapy. Behavior Therapy, 35, 639-665.


  1. Is there a cohesive "third wave?" There seem to be substantial differences between the treatment methods, theoretical groundings, and inspiration among the schools (e.g. ACT, MBCT, DBT) Hayes lumps together. Sure, you can say they are all "mindfulness based," but 1) the theoretical definitions vary 2) theories have a long history of leading psychology into some wacky places and 3) as above, the operation varies. I'd like to see the science guided by a broad-minded host of "third wave" inspirations, rather than one - everyone let's put our new paradigm blinders on - theoretical underpinning.

  2. Good point, Jeff. Third wave is "a" way of grouping a collection of treatments but is not necessarily "the" way. I've heard that Marsha Linehan wasn't happy that Hayes included DBT! My guess is that part of Hayes's purpose was to brand a movement and create more cohesion within it. To that end, it was pretty successful, as the term has caught on. You're right in that there are theoretical differences among the treatments.


Note: Only a member of this blog may post a comment.