Third-Wave CBT or three waves of CBT ?

Both are correct! As already explained in my previous article (CBT what’s all the fuss about, 2018) Cognitive Behavioural Therapy is an umbrella term for a range of therapeutic models that successfully combine behaviourism with Buddhist philosophy, social learning theories, cognitive psychology and more recently neuroscience/ neuroaffective research (Mirea and Hickes, 2012)1. A number of different CBT approaches have gradually evolved over the last 70 years, in three distinct waves (Mirea, 2012)2.

In spite of some apparent differences, all of these methods have much in common. They are formulation-based 3 and rooted in empirical research, behaviourism and the bio-psychosocial model4. They have a common framework, the working models are simple enough and easy to learn, with clear therapeutic goals, which are agreed collaboratively with patients by employing a SMART 5 approach (Mirea, 2016) 6. Therapy goals would usually involve carefully planned strategies aimed at disrupting factors that predispose and trigger individuals’ mental health symptoms and maintains the crisis through rather complex mechanisms usually designed at an earlier stage in life.

Here is an example (published in 2012 article by Mirea and Hickes)1. An excessively jealous and anxious boyfriend revealed in therapy that during his childhood, he experienced significant emotional neglect and an unpredictable and explosive parental relationship, including regular fights, arguments, cheating and jealousy. He internalised all these episodic and emotional, childhood experiences in a particularly disintegrated manner and developed a core-belief (a powerful felt-sense) that he is unlovable (and if found out he would be rejected). This is not usually dialectically expressed with peers or significant others, but it is more of a sense-of-self, a gut-feeling or an identity that the individual has created for himself, based on his early years (emotional) experiences. Over time, the patient would ensure that he is well defended against all of the possibilities that he will be rejected and covers up for his perceived flaw by developing a number of strategies meant to ensure his survival and happiness. Some behavioural strategies will therefore be based on the assumption that “I have to always be on my toes in a relationshipthe moment I let my guard down, she would cheat on me”, therefore… “It is justified to be jealous; I will stalk her, check on all her movements all of the time, I’ll go through her mobile phone records and pockets (and so on…), in order to be better prepared”, etc.

Any future therapeutic work, should help the client identify where these complex set of beliefs, associated behaviours and emotions are exaggerated or misguided. During the assessment, the therapist designs a case formulation containing vicious circles (or traps) that help educate the client about the relationship between his early childhood experiences, core beliefs, assumptions, strategies and current critical situations. This formulation or case conceptualisation (which is diagrammatically explained) would act as the basis for a treatment plan.

This article highlights the common ground that all cognitive-behavioural approaches share, the empirical base, the constant focus on change, problem solving and skills development. I have also discussed early treatment processes – the clinical assessment which leads to a case formulation which further leads to strategic treatment planning.

The differences between approaches however, are much more difficult to explain. Fundamentally such differences lie perhaps in the specific design of each method or the original intention. For example, Dialectical Behaviour Therapy (DBT) is a treatment protocol created by Marsha Linehan for Borderline Personality Disorders. Mindfulness-Based Cognitive Therapy (MBCT) is a relapse prevention tool for depression and so on. Of course subsequent research and clinical trials have allowed these methods to be applied successfully with other disorders and this is probably why it may be difficult to figure CBT out at times (especially if one is operating outside of this field).

A historical overview does offer some insights and it shows how dynamic and rapidly this therapy develops. In the very first wave, we have pure behaviourism, highlighted by the reputable and well researched theories of Ivan Pavlov on learning and conditioning, Joseph Wolpe on systematic desensitization, Edmund Jacobson on Progressive Relaxation. The second wave would represent the main body of CBT started off by Aaron Tim Beck’s original cognitive-behavioural therapy and Albert Ellis’ rational-emotive theory. The model is a simple but effective treatment protocol for depression at this stage (1960’s) supported by a range of researched behavioural, learning and cognitive theories. Beck and Ellis had never stood idle but other clinicians such as Donald Meichenbaum (Cognitive Behavioural Modification), Jeffrey Young (Schema Therapy), Adrian Wells (Metacognitive Therapy) or David Clark, to name but a few, have really expanded and pushed the boundaries of CBT in the following 40 years or so. CBT can now be used with a range of disorders, in the short-term or in the long-term. Disorder focused approaches, case formulation approaches, transdiagnostic approaches, have all taken shape during this stage.

Third-Wave, the latest addition, is characterised by the introduction of a new concept which is ultimately going to become very familiar and popular, mindfulness or formally known as Mindfulness-Based Cognitive Therapy. This was introduced to the psychotherapeutic community by Williams, Teasdale and Kabat-Zinn (2007) 7 initially as a relapse prevention method for depression.

In spite of a number of significant developments over recent years, most researchers, authors, and practitioners still draw on the second wave when they describe, challenge or investigate CBT as an approach. This may no longer be sufficient. Studies will have to be more specific about what intervention (e.g. exposure) or method (e.g. MBCT) is being investigated rather than describing CBT in generic terms. I am afraid, this is no longer good enough.


1 Mirea D and Hickes M (2012). CBT and EPT: rival paradigms or fertile ground for therapeutic synthesis. Existential Analysis 23.1, 2012 (p15-31)

2 Mirea D (2012). Cognitive Behavioural Coaching, friend or foe to the existential coach. In Existential perspectives to coaching, edited by Van Deurzen and Hanaway, 2012. Palgrave Macmillan.

3 Formulation or case formulation or (case) conceptualisation can be understood as an alternative to the psychiatric diagnosis, a behavioural analysis firstly introduced in 1965 by Kanfer and Saslow in a seminal paper. Case formulating is part of the assessment process and it is central to providing a coherent and comprehensive treatment plan.

3 The biopsychosocial model (bio-psychosocial or bio-psycho-social) is a broad view that attributes disease outcome to the intricate, variable interaction of biological factors (genetic, biochemical, etc), psychological factors (mood, personality, behavior, etc.), and social factors (cultural, familial, socioeconomic, medical, etc.). The biopsychosocial model counters the biomedical model, which attributes disease to roughly only biological factors, such as viruses, genes, or somatic abnormalities. The biopsychosocial model applies to disciplines ranging from medicine to psychology to sociology.

4 SMART goals: Specific, Measurable, Achievable, Realistic and Timed. A 2014 clinical trial by Waller et al. pointed out that there are clear advantages of the ‘GOALS approach’; it is brief and that the frontline mental health workers who are in regular contact with patients in mental health care settings can be readily trained in its delivery. There is therefore scope for developing an effective intervention, which can be made widely available at low cost, improving access to psychological therapies for this client group. See Waller et al. Trials 2014, 15:255

6 Mirea, D (2016). Assessment and case formulation in CBT. Revised 1999 article and re-published in April 2016 in the Family Wellbeing Research and Therapy Journal. Vol.3. 1-24

7 Williams, Teasdale, Segal, Kabat-Zinn (2007). The Mindful Way Through Depression: Freeing Yourself from Chronic Unhappiness. The Guildford Press.

How to best confuse yourself when you are already stressed…

In a few words… start googling, binging or ask Alexa !

If I knew nothing at all about ‘mental health‘ and googled for some help with my stress or anxiety levels, I would probably end up focusing on the only criteria I can understand – money ! What is the cheapest therapist out there or how do I get the best value for my money. Nothing else on Google makes any sense, when it comes to psychotherapy, unless you have a degree in research methods.

The answer to the ‘value for money question’ however, is relatively simple: NHS is by far the cheapest service, because… it is actually free. However, since getting any kind of mental health support from your GP is like pulling teeth, you have no choice but to go private. Unless you are a high risk, it is unlikely that you will get anything else besides leaflets and SSRIs 1 via your local general practitioner.

Incidentally, I am a big supporter of antidepressants and the work GP’s are doing on a daily basis is simply award worthy. I know too many cases where lives have been saved by SSRIs and an outstanding GP support however, I am not a big fun of random prescribing without a thorough MSE (mental state examination 2). GP’s are not psychiatrically trained and nor should they be – this is a highly specialist area reserved for mental health specialists; though what is worse is that, most are not provided with any mental health support on site.

Now… on the other hand, therapists are not making life any easier for their patients with endless squabbles over supremacy and the never ending ‘which school of therapy is more effective’ competition. In this process, we tend to lose track of our patients’ needs and instead we focus on offering them what we were told in training that works best. All the while, the poor victims of mental illness cannot even tell the difference between psychiatry, psychology, psychotherapy or hypnotherapy and wait… there is at least one more… of course, counselling 3 … and life coaching… and mindfulness therapist.. and existential coaching.. and it goes on and on… Everyone out there seems trained to come to the rescue.

But Thank Goodness for Google! Because when it comes to creating even more confusion it wins the prize.

One of my least favourites Googles is self-diagnosis ! Simply too many patients come to their assessment with an already Google-made diagnosis. As such, here are just some of the problems that I have with that:

  • It is far too easy to misinterpret physiological symptoms and identify with the incorrect diagnostic criteria; e.g. mood swings do not necessarily equate with a manic-depressive illness !
  • Patients can throw mental health assessors off with their perception of a medical history which could have been at best influenced, if not completely constructed with assistance from Google or its competition Alexa !
  • The issue of chronic medical problems. Patients often think they have panic disorder (a very common self-diagnosis) and miss the diagnosis of hyperthyroidism or irregular heartbeats. On the other hand, heart racing does not (necessarily) means that one is having a heart attack.
  • Confusing one psychological disorder with another. For example, some patients may think they are overwhelmed by agoraphobic reactions which would explain their tendency to socially isolate when in fact, social anxiety or depression or both or even asperger syndrome could be the more likely diagnosis responsible for their social isolation.
  • Self-diagnosis can also create mistrust and may undermine the all essential therapeutic relationship between therapist and patient.
  • Self-diagnosis can precipitate and perpetuate health anxiety.
  1. SSRIs: Selective Serotonin Reuptake Inhibitors (SSRIs) are a class of drugs that are typically used as antidepressants in the treatment of major depressive disorder and anxiety disorders, Citalopram, Fluoxetine or Sertraline are just three examples of SSRIs that can be prescribed in UK by the GP or a psychiatrist. Even though clinical psychologists, CBT therapists and mental health nurses have extensive training in pharmacology and psychopathology, prescribing falls under the responsibility of a qualified psychiatrist
  2. MSE – mental state examinations: a clinical assessment process in the psychiatric practice. The purpose of the MSE is to obtain a comprehensive cross-sectional description of the patient’s mental state, which, when combined with the biographical and historical information of the psychiatric history, allows the clinician to make an accurate diagnosis which is subsequently required for coherent treatment planning.
  3. There is no agreed hierarchy in terms of knowledge or expertise when it comes to the title of counsellor, psychotherapist, psychologist or hypnotherapist. However, each of these titles is backed by an accreditation which is essentially a licence, administered by a very specific regulatory body such as BABCP (British Association for Behavioural and Cognitive Psychotherapies), UKCP (UK Council for Psychotherapy) or BACP (British Association for Counselling & Psychotherapy); these bodies demand a certain standard of training, practice and ethics. The least demanding organisations are those that regulate the field of hypnosis, for example the GHSC – General Hypnotherapy Standards Council. Some of the hypnotherapy organisations register hypnotherapists with as little as 21 days of training, minimum or no supervision, no personal therapy and no compulsory clinical practice hours and no core profession (e.g. psychologist or psychiatric nurse for example). The standards of all other counselling and psychotherapy regulatory bodies in UK are significantly different with accreditation subjected to intensive training between 2 to 7 years, clinical supervision, personal therapy and supervised practice. Unlike counsellors or psychotherapists, psychiatrists are medical doctors trained in psychiatry (mental health diagnosis, pharmacology, etc.)  but not in counselling or psychotherapy (or talking therapies). Clinical psychologists are also doctors in psychology trained in talking therapies. All BABCP accredited CBT therapists are post-graduates and/or doctoral psychotherapists (with a core profession) specialising in psychological and behavioural treatments (rather  than generic counselling).

CBT, what’s all the fuss about ?

Well.. most rumours are actually true. At least according to Frontiers of Psychiatry (the January 2018 edition) CBT is the gold standard in the field of psychotherapy, because of its clear research support and continuous development and improvement based on research findings. It presently dominates the international guidelines for psychosocial treatments, making it a first-line treatment for most disorders, as noted by the National Institute for Health and Care Excellence’s guidelines 2 and American Psychological Association.3

This is no longer the new kid on the block, even though it was the latest to join in at the big boys table in the mid-60’s. Back then, CBT was merely a treatment protocol for depression written by the brilliant Aaron Tim Beck an analytically trained psychiatrist. The clinical world soon realised that this new kid nicknamed by Beck CBT, is here to stay and might even attempt to take over. So much so that today, we are talking about CBT being an umbrella term for a number of therapies or approaches with many strange names but a clear task to treat a variety of different psychiatric disorders (i.e. Schema Therapy, SIT, PE, MCT, MBCT, DBT, ACT, CFT and a lot of other acronyms).

CBT is a pretty fast paced, short-term, modern therapy with flexible therapeutic boundaries. Yes that’s correct fellow therapists, behaviourists have always steered away from traditional psychotherapeutic boundaries – in my humble opinion, these dated boundaries are probably still rooted in an unworkable Freudian-psychoanalytical approach. I am sure this is a gross exaggeration, but nonetheless it does not change the fact that CBT does not necessarily adhere to the traditional therapeutic boundaries. Whilst some therapists still wonder over the usefulness of shaking hands with their patients or comforting someone crying, we stick our hands down the toilet to demonstrate to our OCD patients that germs don’t instantly kill.. and then we shake their hands! Sessions can take place in the comfort of a clinic (if we are lucky enough) or in patient’s residence or outdoors or at patient’s work place. It all depends on the type pf exposure exercises or social experiments that we would have agreed on, in advance, with the patient.

The formal term used in CBT is ‘collaboration’. Indeed we collaboratively agree on most (if not all) experiments but in reality, this model is directive, problem-solving and goal oriented, relying on a lot of teaching and a clearly prescribed evidence-based process usually led by an expert therapist (oh yes.. I’ve done it again). The treatment methods (from exposure to relaxation training) are steeply rooted in behaviourism, learning theories and even physiology. The works of Skinner BF, Watson J, Pavlov I, Jacobson E, Salters A and a few other creative but not always popular (or even ethical by today’s standards) behavioural psychologists from the beginning and middle of the 20th century, form a solid foundation for all CBT approaches.

Nowadays cognitive-behavioural practitioners describe methods spreading over three distinct waves of CBT. The first wave is steeped into the experimental work and research of early behaviourists, the second-wave was kicked off by pioneers such as Aaron T Beck, Albert Ellis and Donald Meichenbaum and this would be ‘the CBT’ that most people are familiar with !

Third-wave CBT is marked by a slight departure from earlier methods with the arrival of imagery-based and philosophically informed approaches such as mindfulness and acceptance therapy (aka MBCT or ACT). Even though though mindfulness, acceptance and compassion-based therapies are associated with the Buddhist philosophy it is important to acknowledge that the main drivers that underpin these methods, developed by true visionaries like Jon-Kabat Zinn, Williams M, Teasdale J, Segal Z or Gilbert P, are not the philosophical aspects of our daily living as much as, a covert focus on training the attention with the purpose of affect regulation.

What else do all these therapies have in common, would be a topic worthy of a whole new article…

Introducing NeuroAffective-CBT

Neuroaffective-CBT or on short NA-CBT is a transdiagnostic and modular therapeutic model developed and refined over the last 12 years by Daniel Mirea. As described in the opening comment this approach was born out of a need to better understand and better respond to deeply rooted emotions that ‘feel’ too complex and confusing to most people who have never been strangers to painful and unmanageable affective experiences.

Often such affects (or emotions) are difficult to describe and may fall under the low self-esteem umbrella, shame or guilt. But not only… I find in my classes (I teach qualified practitioners at a post-graduate and doctoral level mostly) as well as in my clinical supervisions that psychotherapists are often guilty of assuming too much. Patients or clients (depending on where one is practising psychotherapy) are often confused about their affective states and even appropriate transient emotions such as fear, sadness or fleeting anger can be often misread or misunderstood, which of course leads to an amplification of unwanted emotions.

In any case, to begin with it may be important to define the concept of ‘transdiagnostic’ and ‘modular’ psychological treatments. Transdiagnostic approaches evolved in CBT in response to a range of symptoms that often cross the boundaries of a specific diagnostic criteria.

In other words, emotions such as shame, guilt and low self-esteem are consistent with symptoms that can be found in depression, social anxiety, personality disorders or even PTSD. NA-CBT is a transdiagnostic approach because it can be used with any of these psychiatric disorders since it aims to undermine the maintaining mechanisms that reinforce the presenting problems. The diagnostic criteria, although extremely important is not necessarily the main driver during therapy.

NA-CBT is also a modular approach because, just like in the structure below, the treatment can be split into different modules. The reason I have not labelled those treatment phases or treatment stages is simply because in NA-CBT, these modules do not follow a rigid order, modules are intersectable and interchangeable. This means that one can start the treatment with module 3 and then move on to module 2 depending on patient’s therapeutic goals, needs and ability to learn new coping skills.

For example with traumatic memories such as that of an emotional abuse (e.g. being humiliated and shouted at during earlier years), such memories may need to be processed more immediately, as suggested in module 3 – The integrated Self, before returning to module 2 – where the focus would be on Physical Strengthening.

Sometimes, it may appropriate to work through both modules in parallel. During the Physical Strengthening module, we ask patients to be more aware of their bodies, their posture and musculature action, since those have a direct and reverse impact on how we feel about ourselves. Our mind instructs the body but the body also instructs the mind. For example, where appropriate I would explain to patients, about the direct impact of shameful feelings onto our physical posture (musculature) and body language overall. Internal self-awareness and managing our focused attention becomes an important aspect of the training at this stage also.

An easy to remember model called TED is also part of the Physical Strengthening module:

  • Tired (energy levels and sleep deprivation)
  • Exercising (physical exercises)
  • Diet (drinking & eating)

You can only imagine my excitement when my son introduced me to a comedy with the same name a few years ago; turns out that TED is a cute teddy bear with a flair for excitement and fun but more importantly he is the main hero’s best friend. So Yes indeed… “TED’s your best friend” and “When in doubt check with TED” is the type of catchphrases popular with my clients even today. In future posts, I will be writing more about the benefits of using catchphrases, fun relatable stories and metaphors in therapy. And along the same lines, about the benefits of appropriate self-disclosure.

Neuroaffective research points out that an integrated or balanced sense-of-self, an improved confidence and well-being can be achieved through better hormonal regulation. A lot of (psycho)education and training is offered on how to achieve ‘balance’ and well-being through improving emotional-hormonal regulation.

Recent neuroaffective and neuroimaging research has influenced CBT treatments over recent years and is constantly shaping therapists’ understanding of brain wiring and the relationship between brain circuits, hormonal regulation and primary emotions.

An overview of the NA-CBT treatment toolkit:

  • Assessment and case formulating: the “Pendulum-Effect” case formulation: since all CBT treatment protocols begin with a thorough assessment, where the principle purpose is to arrive at a formulation which will then form the basis for the treatment plan, I do not consider this initial stage a module. The assessment and case formulation plays a pivotal role in the treatment – this is not a ‘negotiable’ phase but a treatment condition. During this initial stage however, a strong emphasis is placed on building an alliance and a strong therapeutic relationship by using (uniquely to NA-CBT) methods such as emphatic mentalisation.
  • Module 1 : Psychoeducation & Motivational Enhancement: including building motivation, enhancing self-efficacy, problem solving skills training.
  • Module 2 : Physical Strengthening: TED’s your best friend
  • Module 3 : The development of an integrated-Self: cognitive reframing (appraisal-reappraisal). Traumatic memories processing (through bilateral stimulation, narrative exposure and/or reliving).
  • Module 4 : Coping Skills Training & Self-Regulation – including Mindfulness, Self-hypnosis and/or Relaxation Skills Training and also introducing EDRB’s (Emotion-Driven Reinforcing Behaviours)
  • Module 5 : Skills Consolidation and Relapse Prevention – this is all about future plans…

Where can you get training in NA-CBT

In London, NA-CBT is introduced to post-graduate students via CBT modules at Regents University or at the Existential Academy (via Middlesex University) on their advanced post-graduate and doctoral programmes. An introduction or overview of the model is also on offer at other organisations where Daniel Mirea regularly teaches including UK College of Hypnosis & Hypnotherapy (training organisation focused on Hypno-CBT, CBT and evidence-based psychology only). Since this is advanced cognitive-behavioural training and the approach places itself under the umbrella of CBT therapies, it is not presently offered outside the psychological, psychiatric and CBH community which means that one would have to have a core mental health profession or to at least be accredited in Cognitive-Behavioural Hypnotherapy (CBH) before attending training in NA-CBT.

Daniel Mirea
CBT Consultant & Senior Lecture