Third Wave Interventions Flashcards
What are first wave interventions?
Focused on classical and operant conditioning
Behavioural therapies
What are second wave interventions?
Focus on information processing and addressing content
Correcting distorted beliefs, emotions etc
Cognitive behavioural therapies
Dialectical behaviour therapy
Linehan (1993)
Developed to help address emotional instability, self-harm, personality-level problems
Elements of dialectical behaviour therapy
Individual, group and phone contacts Behavioural change and self-control Cognitive work to address black-and-white thinking Mindfullness Comprehensive validation
Comprehensive validation
Most active element of dialectical behavioural therapy
Understand what the problem is, why they have had it so long, why they still have it, but don’t accept why they can’t change it now
Evidence for DBT
The leading therapy for borderline personality disorder
Limited outcomes in other disorders
Schema therapy
Young et al. (2007)
Developed to help schema-level beliefs, and hence to address personality disorders
Elements of schema therapy
Addressing unconditional core beliefs (abandonment, defectiveness)
Schema mode work (limited reparenting, imagery re-scripting)
Evidence for schema therapy
Evidence in treating borderline personality disorder and antisocial personality disorder
Limited evidence in other disorders
Acceptance and commitment therapy
Hayes et al. (2012)
Developed to cover a range of disorders
Elements of acceptance and commitment therapy
Behavioural analysis (centred on the context of the behaviours)
Acceptance strategies to replace avoidance strategies
Mindfulness to identify avoidance patterns
Choosing and acting on a more positive option
Evidence for acceptance and commitment therapy
Supported in treatment of depression, anxiety and addiction
Relative to placebo and treatment as usual (the usual treatment used)
Solution-focused therapy
Pichot et al. (2003)
Not diagnosis-centred, but focused on what the individual wants to achieve
Elements of solution-focused therapy
Focus on action in the here and now, and in the future
Based on understanding how current problems developed
Development of problems = complicated; solution = simple
Focus on competencies and ability to find solutions (problem-free talk)
Miracle question (used to help the client envision how the future will be when the problem is gone)
Evidence for solution-focused therapy
Some evidence in small studies, but nothing major
Compassion-focused therapy
Gilbert (2009)
Developed to help address issues of shame, guilt etc. (common issues in depression, abuse histories)
Elements of compassion-focused therapy
Traditional CBT elements
Evolutionary perspective
Training in being more self-compassionate
Evidence for compassion-focussed therapy
Widely used across disorders, but mainly pilot studies
Limited evidence so far
Biggest impact seems to be on self-criticism rather than specific symptoms
Mindfulness-based CBT
Segal et al. (2002)
First developed for depression
Elements of mindfulness-based CBT
Routine CBT
Mindfulness training/mindfulness meditation - focus on the here and now experience, acceptance without judgement, not returning to past events and unhelpful cognitive patterns
Evidence for mindfulness-based CBT
Effective in reducing relapse in recurrent depression
Beneficial in a range of physical disorders (e.g. pain)
Reduced craving-based behaviours (e.g. smoking)
Mindfulness-based stress reduction
Kabat-Zinn (1998)
First developed for depression
Elements of mindfulness-based stress reduction
Mindfulness training/mindfulness meditation
Evidence for mindfulness-based stress reduction
Effective in reducing stress
Some positive benefits for anxiety and depression, but not strong or consistent effects
No strong evidence of benefits for physical illness
Metacognitive therapy
Wells (2011)
Developed to address anxiety and depression
Elements of metacognitive therapy
Focus on cognitive maintaining processes (worry, threat monitoring, ineffective coping behaviours)
Attention training
Detached mindfulness
Evidence for metacognitive therapy
Some early evidence in depression and anxiety (but with very small samples)
Weak-moderate effects so far (more comparison with existing therapies is needed)
How does mental health differ from physical health?
Medications are specific to the disease, whereas treatment for mental health doesn’t just depend on the disorder, but multiple factors about the individual case
Common themes in third wave therapies
Sound a lot ‘cuddlier’ than the first and second therapies (clinicians are often reluctant to use evidence-based approaches if they are seen as harsh, so are ‘nicer’ sounding therapies more likely to be used?
What needs to be decided about third wave interventions?
Do they represent advances on existing first and second wave therapies?
Are they fashions that will be abandoned?
Butler et al. (2006)
Summary of meta-analyses up to 2006
Shows that CBT is effective
Was CBT a step forward from behavioural therapies?
Not necessarily
Exceptions in social anxiety and bulimia nervosa
Usually takes longer to come to the same outcome
Ost (2008)
Majority of the evidence for these therapies lies in ACT and DBT
Compared effects with existing CBT, other therapies and treatment as usual - generally equivalent
No evidence of a step forward
Ost (2014)
Updated meta-analysis regarding the effects of ACT, in light of additional evidence
Still no evidence of superiority to other treatments
The effect of ACT had become weaker with time (ES 0.68 in 2008 to 0.42 in 2014)
Quality of ACT research was unimproved (remains weaker than comparable CBT research, weakest studies had the largest effect sizes)
Still no step forward
Issues of (mis)application - compassion-focused and mindfulness-based approaches used widely with NHS staff
Francis Report (2013) concluded that we need clinicians who are compassionate to patients
However, these approaches have the aim of developing self-compassion (and usually do so) but not the aim of compassion towards others that is needed
Issues of (mis)application - the behavioural/CBT element is critical to many of these evidence-based versions of third wave therapies
This is commonly omitted in everyday practices
E.g. commonly see mindfulness-based stress reduction used rather than mindfulness-based CBT
Issues of (mis)application - are we fashion victims?
Prone to focus on the latest thing, and giving it up when it becomes routine?
Style over substance?
Should we start preparing for the fourth wave now?
Conclusions - waves past
There is clear evidence that behavioural approaches work (wave 1)
CBT is not very much more effective than behavioural approaches (wave 2)
Third wave approaches are
- Sometimes as effective as CBT
- Certainly not better
In all cases, the removal of the behavioural element is a problem (cognitive therapy vs CBT; mindfulness-based CBT vs mindfulness-based stress reduction)
Conclusions - waves future
More high-quality research is needed on third wave therapies (especially those that are little researched to date)
Work harder on treatment-matching (more about trial and error, what works for the specific patient, try something and change it if it isn’t working)
Might be better to stop thinking of all these therapies as belonging to a common group and treat each with its own merits
We are great at getting about 50% to recovery (add on 25% in the improved group)
Challenge is getting 100% recovery
