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.

Acceptance and Commitment Therapy Vs. Cognitive Therapy for the Treatment of Comorbid Eating Pathology

Recently, a group of researchers at Drexel University--including Dr. James Herbert, who we interviewed about mindfulness over the summer--conducted a study comparing Acceptance and Commitment Therapy (ACT) and Cognitive Therapy (CT) for disordered eating. Juarascio and colleagues looked at people in treatment with "subclinical eating pathology"--meaning that most people identified problematic eating behavior but didn't qualify for an official eating disorder diagnosis.

Although CBT is considered the gold-standard for eating disorder treatment, some research indicates only 30-50% of people completely stop binging and purging, according to research cited by the authors. Consequently, there seems to be some room for improvement.

This study appears to have been culled from the leftovers from a previous study of ACT and CT treatment for anxiety and depression (Foreman et al., 2007), that it was pulled from the same data set. It looks like the authors found that a number of participants (N = 55) from the data set reported eating disordered behavior and ran additional analyses on these individuals.

This study is what is known as an effectiveness study. It doesn't have the control of an efficacy study, but it plays out closer to what happens in real life. This makes it more naturalistic. (Click here for a quick explanation of efficacy vs. effectiveness.)

Participants agreed to the study and were randomly assigned to either an ACT or a CT therapist. These were students at a post-baccalaureate institution who received treatment from one of 23 doctoral students trained in both ACT and CT. Therapy was not conducted through a manual or protocol, as would happen in an efficacy study.

The researchers predicted people who received ACT would show greater improvements than those who received CT, and analyses supported this hypothesis. Although CT lead to small improvements in eating disorder behavior, ACT led to very large improvements.

Because treatment wasn't manualized, we don't know exactly what components of CT and ACT were drawn upon in therapy. In addition, CT participants didn't necessarily receive gold-standard CT protocols for eating disordered behavior. In fact, as they note, the researchers are not certain if  eating disordered behavior was a focus. And, as was noted, the eating disordered problems were generally subclinical. For these reasons, this study cannot be considered a test of a gold-standard cognitive behavioral treatment for eating disorders against ACT.

That said, this study has wonderful real world validity. If someone with eating disordered problems walked into a CT or an ACT therapist's office, this is the kind of treatment he or she may be likely to receive. Fewer clinicians use the kind of manualized treatments that are used in more controlled studies (e.g., RCT's), although knowledge of manualized treatments can be very useful in real world practice.

This study provides pretty good evidence for the effectiveness of ACT in addressing eating disordered behavior. ACT promotes greater mindfulness, acceptance, and movement towards valued directions; by contrast, CT focuses on changing the content of one's thinking. Results suggest ACT processes of change may be more appropriate for individuals with eating disordered problems than CT processes.

Drs. Forman and Herbert have large collection of their research available as PDF's on their Drexel research lab page. Click here to download a copy of the article.

For the full citation:

Juarascio, A. S., Forman, E. M., & Herbert, J. D. (2010). Acceptance and Commitment Therapy versus Cognitive Therapy for the treatment of comorbid eating pathology. Behavior Modification, 34(2), 175-190.