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 relationship…the 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.

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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.