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Sharkey August 4th, 2004 06:58 PM

Third Wave Behaviour Therapies and CT
How is cognitive therapy responding to the "third wave behavior therapy" position. It seems to me that these approaches are coming at the whole issue of mental health so differently that it becomes impossible to reconcile the two positions. How do other people feel about this? Is there a way of proceeding by integrating these emerging approaches with the Cognitive Therapy tradition ?

JustBen August 5th, 2004 10:09 AM

Third Wave Behavior Therapies
I don't feel that I understand enough about this "third wave" to respond, Sharkey, so maybe you can educate me. I've heard of this movemement, and I've even explored some of the techniques and approaches that characterize it: Dialectical; Acceptance and Commitment; Mindfulness; Functional Analytic, etc. What I can't figure out, however, is what unites these approaches into a "wave". What do they have in common that makes them part of a common movement?

Sharkey August 7th, 2004 07:42 PM

Re: Third Wave Behavior Therapies and CT
Yes I think that it can be difficult to describe the characteristics that distinguish these approaches as a separate group. However, for me they are typified at the clinical level by interventions like mindfulness, acceptance and validation, dialectics, values and cognitive defusion. Experiential interventions seem as important, or usually more important, than didactic ones. Direct challenging of cognitive content is eschewed in favour of interventions (like some of those mentioned) that seek to change the nature of the relationship the individual has to her/his cognition generally. Also spirituality and relationship are emphasised in these approaches.
The "Third Wave Behavior Therapies" remain allied to the empirical core identified with behavioral therapies generally (though much of the above is generally associated with less empirically-based approaches).

My training has predominantly been in Cognitive approaches (Beck, Ellis,). These have very explicitly emphasised the need to change cognitve content in order to change "bad feelings" (e.g the Daily Thought Record has been a central intervention, see Padesky and Greenberger's Mind over Mood for instance). The "Third Wave" approaches seem to teach a radical acceptance of private experience and would often regard the challenging of cognitve content as an example of dysfunctional control attempts or as invalidating of the client's experiences. The latter often advocate a willingness to be present with feelings and emotion and more established CBT interventions are only used to assist this goal. I cannot see at this point how these positions can be reconciled.

Beckian CT seems not to give any central role to values and the activity scheduling intervention, for instance, seems to prescribe a general increase in activity because of its likely anti-depressant effects rather than choosing actions as part of living a more valued life generally (stressed, for instance, by Hayes et al., Jacobson etc). Also is it appartent why Cognitive therapists, given the underlying theory, would utilise experiential interventions, mindfulness-based interventions etc?

My original question was asking if people can see a way of integrating these recent developments with CT. I suppose the question was asked because I am finding difficulty doing this.

Dieter Dvorak August 8th, 2004 11:57 PM

Re: Third wave of behavior therapy and CT
If one takes a very purist stance then it would be very difficult to integrate standard CT with mindfulness/acceptance based therapy. This because CT essentially does agree (collude?) with the client in that the change in cognitive content is supposed to facilitate/cause change in emotional experience and corresponding behaviour. The implicit message is: it would be really bad if you felt like that but you can change your experience through changing the content of your thinking. Mindfulness/acceptance based therapy on the other hand gives the message: we're compassionate about you having this experience AND part of your problem is that you don't want to have that experience AND your feelings and thoughts are just that, namely thoughts and feelings you don't have to act upon. Mindfulness/acceptance is definitely not just another "little technique" as it is presented sometimes by second wave therapists.

In practical terms I think we need to meet our clients were they are in regards to their culture, education and upbringing. For most people living in a "western culure" this means a high premium is put on analytical thinking and concrete problems solving, which both are discouraged in mindfulness/acceptance approaches (at leas to some degree).
However, even stock standard CT techniques such thought record and doing a "5 part model" do contain elements of non-judgemental observation of external and internal stimuli. Therefore it seems very possible, or maybe even necessary for some clients, to "prepare the ground for mindfulness/acceptance strategies through conventional Ct techniques which already facilitate some "decentering/development of an observer self".
(See also research on efficacy of MBCT between clients with only 1 or 2 depressive episodes compared to those with more than 2!).

It also seems very useful to use CT techniques to elicit the clients intermediate or core beliefs/schemas which facilitate ruminative processes through comparing and judging one's external and internal environment against some sort of ideal standard and expectation (again see MBCT model). Then, of course the decision will have to be made as to promote the "restructuring" of these beliefs (and derived automatic thoughts) or the non-reactive observation of them.
Having a reasonably coherent model of how mindfulness/acceptance intervenes in the otherwise incessant process of comparing and judging and behavioural responding to internal and external stimuli will be helpful in the therapy process of shifting the clients awareness from the content to the process of cognition (including processing physiological and emotional experiences).
From my own experience, it seems possible to integrate CT with mindfulness/acceptance strategies in a staggered fashion whereby cognitive restructuring prepares the ground for genuine mindfulness/acceptance work. It also depends on the severity of the client's presentation and the degree of the "irrationality" of their thinking. The more the client's distress stems from "dysfunctional" cognitions the more appropriate is CT. The more distress is attributable to realistic cognitions (about real life problems such as death of partner, own illness, financial situation etc.) paired with non-acceptance of these inevitable (in the moment) stressors the more mindfulness and acceptance based work appears to be the way to go.

These are exciting times and we may see a development that rivals that of the advent of BT or CT.

JustBen August 10th, 2004 10:39 AM

Third Wave Behavior Therapies
This is an excellent thread, Sharkey, because it forced me to do some research and critical thinking. I was pleasantly surprised at just how much empirical support I found for "third wave" approaches, but I found nothing that would indicate that it could be integrated into the CT "orthodoxy". As an individual, you could use both approaches in a manner described in the last paragraph of Dieter's post, but I would tread very carefully in that terrain. One possible conflict that immediately springs to mind: In CT, it's expected that the clinician will clearly explain the cognitive model at the beginning of therapy. The patient's intellectual understanding of the relationship between cognition and affect are supposed to serve as a kind of bedrock for real change and enhance the therapuetic alliance by serving as an experience in which the therapist shows that he/she knows what they're talking about thereby instilling confidence in the patient. If, however, you go through this process and then, at some point, introduce "acceptance" (which, at least in appearance, seems to conflict a major aspect of the cognitive model that you've invested so much in "selling" to the patient) then you've cracked that bedrock, underminded the patient's basis of a belief in change, and their confidence in you as a clinician.

Paul J. Robinson August 10th, 2004 04:55 PM

Re: Gerry
I too have struggled with some of the developing ideas already mentioned, in the context of my CBT practice. However, in a number of ways, the current practice of CBT, perhaps moreso for some disorders than others, does seem to emphasize acceptance and the processes of a person's psychology, and pays less attention to content .

For example, for quite some time now, it has been argued in the CBT literature and clinical community that challenging the content of the thoughts of those who are obsessive-compulsive, or who are worriers, often is not successful or advisable. Instead, in such cases it is advocated that there be an attempt to accept the thoughts as occurring, and more of an emphasis on assisting the person to not take them seriously, not react, to disengage, etc.. As well, people like Adrian Wells are less interested in the content of automatic thoughts, and will target meta-cognitions that contribute to the maintenance of something like the tendency to worry. Reid Wilson's recent work has emphasized not just acceptance of thoughts, but active "wanting" of them, in the service of then becoming less afraid of them. In the treatment of GAD, Michel Dugas advocates increasing the person's tolerance of uncertainty. In my reading of these developments, they have all occurred in the context of the evolution of CBT, and are very consistent with this so-called third wave. All this said, as others have already mentioned, it seems difficult to reconcile some apects/philosophies of each approach.

Dieter Dvorak August 10th, 2004 09:19 PM

Re: Ct and third wave of CBT
Elements of acceptance/mindfulness based therapeutic work certainly have a long tradition within CBT and other approaches of psychological therapies. (I have a copy of an old text on Gestalt therapy in front of me : gestalt is, 1973, edited by John O. Stevens, which contains chapters on mindfulness)

Exposure with response prevention techniques such as the one mentioned for OCD are prime examples of acceptance based pure behavioural treatments.
The main difference to "third wave" approaches is that the latter explicitly and specifically address the client's relationship with aversive external or internal stimuli rather than trying to challenge the aversive quality of the stimuli (CT) or to ignore them (BT). An interesting read about pure exposure treatment for OCD may be Schwartz's book "brainlock" and "the mind and the brain". :eek:

To reiterate my earlier point and support what has been said in the last two postings: it is definitely very useful and necessary to create a collaborative atmosphere with the client through presenting a model the client can identify with and "buy into". The MBCT (Teasdale et al.) model, which together with the ACT (acceptance and commitment therapy, Hayes et al.) model and Kabat-Zinn's MBSR model are great steps towards an integrative cognitive-behavioural model that is focused on process issues (i.e. schema influenced perception, comparison, evaluation, motivation and choice) while integrating everything that has proven to be useful and empirically valid from the entire "standard" CT/Schema focused T/CBT/DBT/REBT/BT therapy spectrum (and even beyond).Such a model- if digestible by the client- could facilitate a combined cognitive-behavioural restructuring AND acceptance therapy process.
Let's not get side tracked by the apparent contradiction between content and process. Carefully presented explorations of the accuracy and origins of cognitive content can help the client understand how he/she gets "sucked into" the largely automatic process of responding (cognitively, emotionally, physiologically and behaviourally) to a particular environmental context - or its mental representation in form of memories or anticipatory imagery. Knowing that - and how - one's core beliefs/schemas guide one's intermediate beliefs (i.e. shoulds, if...then) can help to accept/let go of one's own response, underlying schemas and dysfunctional behaviour (Blend of schema therapy with mindfulness can be found in : "Emotional Alchemy" by Tara Bennett-Goleman).
Developing a strong sense of one's own values can be done using Hayes' ACT approach and integrating Seligman's ("Authentic Happinness") approach to 'positive psychology'.

The "third wave" seems more like a paradigm shift in looking at mental health, which when complete, can integrate a great number of existing efficacious interventions from quite different approaches. :)

Sharkey August 12th, 2004 05:22 PM

Re: Third Wave Behavior Therapies and CT
I appreciate these very thoughtful responses. However, I still think that there are problems. For instance, the rationale for targeting the content of negative automatic thoughts suggests that the content of those thoughts is the problem...the problem, that is, in the sense that the existence of this content helps to generate or maintain the bad feelings and unhelpful behavior patterns. Acceptance approaches would seem to suggest that the content is not the problem. On the contrary, these approaches seem to say that it is precisely this position, promoted by the current cultural zeitgeist, that impels people to engage in unnecessary and harmful control efforts with regard to their thoughts and their other private experiences. It would seem confusing, to say the least, if the therapist suggests to the client that they should control their bad thoughts by challenging their content and replacing them with more balanced alternatives on the one hand and then later proposes that "control is the problem" and thoughts should be accepted. I wonder if the idea of integrating the interventions identified with third wave bt's represents an integrative step too far and that the positions proposed by the latter simply cannot be integrated into schema theory in any credible way.

Maybe the problem is related to the fact that the underlying philosophical positions differ e.g. mechanistic, structuralist and mentalist versus functionalist, contextualist and non-mentalist. This may reflect that most of the third wave bt's would seem to have emerged from the behavioral wing rather than the cognitive one.

Ultimately it may be an issue to be tested empirically if this is possible. I have been interested in the dismantling studies of the late Neil Jacobson and his colleagues, which seem to suggest that the delivery of the behavioral activation component of the classic Cognitive Therapy depression treatment works just as well as the full treatment (which included the behavioral activation component as well as the ones targeting negative automatic thoughts and dysfunctional assumptions). This finding has, I believe, been replicated and surely poses grave difficulties for Cognitive Therapy theory (or is there another way of interpreting these findings?). I believe, in addition, that there is some ACT data that suggests that successful outcomes in that approach are not necessarily associated with drops in the frequency of negative automatic thoughts (sorry, I have no reference for this but if I find some I will post them). Possibly these approaches have their effects through different mechanisms.

James Pretzer September 1st, 2004 10:16 PM

Third Wave (or not?)
Those who are interested in the evolution of Cognitive Therapy over time may be interested in Isabel Caro's article The Way We Were, the Way We Are:Cultural Evolution of Cognitive Therapy which appeared in the Summer II, 2004 edition of the Behavior Therapist . It takes an interesting look at paralells between changes in Western culture and the evolution of Cognitive Therapy. [Please note that Beck and I would argue vigorously against the assertion that CT is a "rationalist" approach. We see CT as a phenomenological approach (see Pretzer & Beck, 1996)]

Personally, I'm not convinced that it makes sense to think of MBSR, DBT, ACT, and MBCT as a "third wave." The four approaches were developed independently at different points in time and have very substantial differences in their conceptual frameworks, theoretical constructs, and therapeutic interventions. Each of the four makes some valuable points but I'm not convinced that they embody a coherent "wave."

James Pretzer September 20th, 2004 10:11 PM

Re: Third Wave Behavior Therapies and CT
In discussing First/Second wave CT an earlier post said "These have very explicitly emphasised the need to change cognitve content in order to change "bad feelings" (e.g the Daily Thought Record has been a central intervention, see Padesky and Greenberger's Mind over Mood for instance)." An important part of the apparent contradiction is the assumption that CT sees explicit efforts to change the content of cognition as a necessary part of treatment. It would be more accurate to say that CT sees interventions directed at changing the content of cognitions as useful in treating many problems, not as being necessary. Those who argue that CT always focuses on changing the content of cognitions misunderstand CT.

It is true that there are a number of problems where CT focuses extensively on changing the content of cognitions. A classic example is in CT for depression where we often spend quite a bit of time modifying the content of automatic thoughts and later work to modify beliefs and assumptions. However, we focus on changing the content of cognitions when treating depression because it works and works well. When treating other problems there often is much less emphasis on generating "rational responses" and much more emphasis on other interventions. For example, in treating phobias there is much more emphasis on in-vivo exposure and much less emphasis on rational responses. A clear example (as noted earlier in this thread) is in treating OCD where it usually turns out that attempts to generate rational responses to obsessions are counter-productive and we emphasize exposure and response prevention.

Some of the approaches that get lumped together as "third wave" approaches are difficult to reconcile with CT. For example, when I've heard Steve Hayes present ACT he's been explicitly anti-CT and he presents ACT as though it's diametrically opposed to CT. Other "third wave" approaches are quite compatible with CT. For example, DBT has some theoretical differences from CT and uses different terminology but there's a great deal of overlap between the interventions used in DBT and the interventions CT uses with borderline personality disorder. MBCT, of course, is a variant of CT which uses "standard" CT interventions such as rational responses in a mindfulness-based framework. Note that MBCT is intended for use when the individual's depression is in remission. I doubt that mindfulness would be a great idea when one is in the midst of a major depression.

If anyone has specific questions about this topic, post them and I'll try to respond. I've got a good deal more to say on this topic but it's late and I need to call it a night.

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