Third Wave Interventions

Question 1

What are first wave interventions?

Answer 1

Focused on classical and operant conditioning

Behavioural therapies

Question 2

What are second wave interventions?

Answer 2

Focus on information processing and addressing content
Correcting distorted beliefs, emotions etc
Cognitive behavioural therapies

Question 3

Dialectical behaviour therapy

Answer 3

Linehan (1993)

Developed to help address emotional instability, self-harm, personality-level problems

Question 4

Elements of dialectical behaviour therapy

Answer 4

Individual, group and phone contacts 
Behavioural change and self-control 
Cognitive work to address black-and-white thinking 
Mindfullness 
Comprehensive validation

Question 5

Comprehensive validation

Answer 5

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

Question 6

Evidence for DBT

Answer 6

The leading therapy for borderline personality disorder

Limited outcomes in other disorders

Question 7

Schema therapy

Answer 7

Young et al. (2007)

Developed to help schema-level beliefs, and hence to address personality disorders

Question 8

Elements of schema therapy

Answer 8

Addressing unconditional core beliefs (abandonment, defectiveness)

Schema mode work (limited reparenting, imagery re-scripting)

Question 9

Evidence for schema therapy

Answer 9

Evidence in treating borderline personality disorder and antisocial personality disorder

Limited evidence in other disorders

Question 10

Acceptance and commitment therapy

Answer 10

Hayes et al. (2012)

Developed to cover a range of disorders

Question 11

Elements of acceptance and commitment therapy

Answer 11

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

Question 12

Evidence for acceptance and commitment therapy

Answer 12

Supported in treatment of depression, anxiety and addiction

Relative to placebo and treatment as usual (the usual treatment used)

Question 13

Solution-focused therapy

Answer 13

Pichot et al. (2003)

Not diagnosis-centred, but focused on what the individual wants to achieve

Question 14

Elements of solution-focused therapy

Answer 14

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)

Question 15

Evidence for solution-focused therapy

Answer 15

Some evidence in small studies, but nothing major

Question 16

Compassion-focused therapy

Answer 16

Gilbert (2009)

Developed to help address issues of shame, guilt etc. (common issues in depression, abuse histories)

Question 17

Elements of compassion-focused therapy

Answer 17

Traditional CBT elements

Evolutionary perspective

Training in being more self-compassionate

Question 18

Evidence for compassion-focussed therapy

Answer 18

Widely used across disorders, but mainly pilot studies

Limited evidence so far

Biggest impact seems to be on self-criticism rather than specific symptoms

Question 19

Mindfulness-based CBT

Answer 19

Segal et al. (2002)

First developed for depression

Question 20

Elements of mindfulness-based CBT

Answer 20

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

Question 21

Evidence for mindfulness-based CBT

Answer 21

Effective in reducing relapse in recurrent depression

Beneficial in a range of physical disorders (e.g. pain)

Reduced craving-based behaviours (e.g. smoking)

Question 22

Mindfulness-based stress reduction

Answer 22

Kabat-Zinn (1998)

First developed for depression

Question 23

Elements of mindfulness-based stress reduction

Answer 23

Mindfulness training/mindfulness meditation

Question 24

Evidence for mindfulness-based stress reduction

Answer 24

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

Question 25

Metacognitive therapy

Answer 25

Wells (2011)

Developed to address anxiety and depression

Question 26

Elements of metacognitive therapy

Answer 26

Focus on cognitive maintaining processes (worry, threat monitoring, ineffective coping behaviours)

Attention training

Detached mindfulness

Question 27

Evidence for metacognitive therapy

Answer 27

Some early evidence in depression and anxiety (but with very small samples)

Weak-moderate effects so far (more comparison with existing therapies is needed)

Question 28

How does mental health differ from physical health?

Answer 28

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

Question 29

Common themes in third wave therapies

Answer 29

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?

Question 30

What needs to be decided about third wave interventions?

Answer 30

Do they represent advances on existing first and second wave therapies?

Are they fashions that will be abandoned?

Question 31

Butler et al. (2006)

Answer 31

Summary of meta-analyses up to 2006

Shows that CBT is effective

Question 32

Was CBT a step forward from behavioural therapies?

Answer 32

Not necessarily

Exceptions in social anxiety and bulimia nervosa

Usually takes longer to come to the same outcome

Question 33

Ost (2008)

Answer 33

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

Question 34

Ost (2014)

Answer 34

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

Question 35

Issues of (mis)application - compassion-focused and mindfulness-based approaches used widely with NHS staff

Answer 35

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

Question 36

Issues of (mis)application - the behavioural/CBT element is critical to many of these evidence-based versions of third wave therapies

Answer 36

This is commonly omitted in everyday practices

E.g. commonly see mindfulness-based stress reduction used rather than mindfulness-based CBT

Question 37

Issues of (mis)application - are we fashion victims?

Answer 37

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?

Question 38

Conclusions - waves past

Answer 38

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)

Question 39

Conclusions - waves future

Answer 39

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