What Is New and What Is Effective ?

and Introduction Abstract Purpose of review: The purpose of this study was to shortly characterize the evolving psychotherapeutic methods summarized as 'third wave psychotherapies' and to review recent research on the therapeutic impact of these methods. Recent findings: 'Third wave psychotherapies' comprise a heterogeneous group of treatments, including acceptance and commitment treatment, behavioural activation, cognitive behavioural analysis system of psychotherapy, dialectical behavioural therapy, metacognitive therapy, mindfulness-based cognitive therapy and schema therapy. Several randomized controlled trials, longitudinal case series and pilot studies have been performed during the past 3–5 years, showing the efficacy and effectiveness of 'third wave psychotherapies'. Summary: The third wave of behavioural psychotherapies is an important arena of modern psychotherapy. It has added considerably to the spectrum of empirically supported treatments for mental disorders and influenced research on psychotherapy. The presented methods open up treatment possibilities for patient groups such as borderline personality disorder, chronic depression or generalized anxiety disorder that had received only little specific attention in the past. The available evidence now allows considering all third wave treatments as empirically supported. Introduction Behaviour therapy has its roots in the 1950s. The characteristic feature of this so-called 'first wave' was a focus on classical conditioning and operant learning. The 'second wave' was characterized by a focus on information processing. Second wave (classical) cognitive therapy is at present the dominant contemporary system of psychotherapy worldwide. A recent review summarizes more than 75 clinical trials for cognitive therapy for unipolar depression that show that this treatment is superior to placebo, equivalent to other bona fide treatments and antidepressive pharmacotherapy. [1] In addition, cognitive therapy seems to be superior to pharmacotherapy and similar to other psychotherapies in its effectiveness in reducing the risk of relapse after discontinuation of treatment. [2] Yet, after more than 45 years of experience with cognitive therapy, there is also a growing awareness of its limitations: first – similarly to other treatments for mental disorders – effect sizes are limited, leaving room for improvement; second, treatments are not universally found acceptable by their users; and third, data are missing that support the necessity of interventions aimed at a content-oriented cognitive change which are core elements of classical cognitive therapy. A review found little evidence that specific content-oriented cognitive interventions such as challenging dysfunctional thoughts significantly increase the effectiveness of cognitive therapy. [3] A component analysis indicates that the efficacy of cognitive therapy depends critically on behavioural activation as only intervention. [4,5] The 'third wave' of behavioural therapies is characterized by themes new to behavioural psychotherapies: metacognition, cognitive fusion, emotions, acceptance, mindfulness, dialectics, spirituality and therapeutic relationship. The techniques used in third wave methods are quite heterogeneous. Commonalities are the abandonment or cautious use of content-oriented cognitive interventions and the use of skills deficit models to delineate the core maintaining mechanisms of the addressed disorders. A further aspect is a renaissance of first wave principles such as operant conditioning. [6] Review The present review focuses on relevant randomized controlled studies after 2007, selected uncontrolled studies The Third Wave of Cognitive Behavioural Therapies Kai G. Kahl, Lotta Winter, Ulrich Schweiger Curr Opin Psychiatry. 2012;25(6):522-528. 7/7/2014 www.medscape. com/viewarticle/772441_print http://www.medscape. com/viewarticle/772441_print 2/10 and selected studies relevant to basic underlying concepts. A meta-analysis of the evidence until 2007 was published by Ost. [7] Acceptance and Commitment Treatment Acceptance and commitment therapy (ACT)[8] is a method of behavioural therapy that is based on functional contextualism and the relational frame theory. It posits the following psychopathological processes as central to mental disorders: (1) cognitive fusion; (2) experiential avoidance; (3) attachment to a verbally conceptualized self and a verbally conceptualized past; (4) lack of values or confusion of goals with values; and (5) absence of committed behaviour that moves in the direction of chosen values. The treatment contains psychoeducation about key mechanisms, exercises in mindfulness and cognitive defusion. The value orientation of the patient is elicited and discussed, and patients are supported in value-driven behaviour in contrast to behaviour driven by emotional or experiential avoidance. [9] There are several randomized controlled trials (RCTs) to test the efficacy of ACT in heterogeneous clinical conditions. ACT was associated with a reduction of depressive symptoms in men and women with subclinical depression. [10•] ACT was superior to progressive relaxation training in reducing symptoms of obsessive compulsive disorder in 79 patients. [11] In substance use disorders, ACT-based psychotherapy combined with bupropione significantly improved smoking cessation compared with bupropione alone (quit rates: 31.6 versus 17.5%). [12] Interestingly, ACT has also been shown to reduce shame in patients with substance use disorders after a 4-month follow-up period, associated with reduced substance use. [13] In 116 patients with nonmalignant pain, an 8-week group therapy was as effective as cognitive behavioural therapy in reducing pain interference and pain-related mood symptoms. [14] An RCT in ACT also addressed nonclinical populations. ACT has been tested versus psychoeducation to promote physical activity in adults. [15•] Healthy adult persons randomized to ACT were more likely to improve their physical activity, pointing to short-term effects of ACT in lifestyle changes. ACT has been shown to be effective in reducing levels of stress and burnout in Swedish social workers (n = 106). [16] Also, several longitudinal studies, case series and pilot studies were published, pointing to usefulness of ACT in pain,[17] eating disorders,[18,19] marijuana dependence,[20] methadone reduction,[21] generalized anxiety disorder[22] and affective symptoms in psychotic disorders. [23] Behavioural Activation Behavioural activation is a third wave method for treating depression and other mental disorders. It emerged from studies analysing the necessary components of classical cognitive therapy. [4,5,24] These studies showed that behavioural activation is a stand-alone component that has a similar or superior efficacy compared with cognitive therapy. Behavioural activation has evolved from a long behavioural tradition seeking to increase positive reinforcement by scheduling appropriate patient behaviours and thus achieving antidepressant action. Important changes compared with earlier versions are a shift from 'pleasant' activities to value-driven activities, a shift strongly influenced by ACT and the adoption of the concept of 'opposite action' from dialectical behavioural therapy (DBT). [25] The goal is to bring the patient into contact with diverse, stable and valued sources of positive reinforcement. Behavioural activation encompasses psychoeducation, activity monitoring, scheduling of antidepressant activities and troubleshooting. The follow-up of an RCT showed that behavioural activation and cognitive therapy had similar enduring effects, which were as efficacious as continuous treatment with medications. [4] An RCT combining behavioural activation strategies with cessation treatment for smokers with elevated depressive symptoms not only showed that this treatment leads to higher rates of abstinence than standard smoking cessation treatment but also that depressive symptoms were lower during the follow-up period. [26] An RCT in geriatric psychiatric inpatients showed a greater reduction in depressive symptoms with behavioural activation than in a control condition. [27] An RCT in female patients with breast cancer and major depression compared behavioural activation and problem-solving therapy. [28•] Large effect sizes were observed in both treatments with similar rates of remission and response. A small pilot study points to good effectiveness of behavioural activation also in atypical depression. Cognitive Behavioural Analysis System of Psychotherapy 7/7/2014 www.medscape. com/viewarticle/772441_print http://www.medscape. com/viewarticle/772441_print 3/10 The cognitive behavioural analysis system of psychotherapy (CBASP) was specifically developed for the treatment of patients with chronic depression. CBASP assumes that skills deficits in the area of operational thinking lead to a failure of interpersonal behaviour and subsequent depression. [29,30] The method comprises three therapeutic techniques: situational analysis, interpersonal discrimination exercise and consequating strategies, all with the aim of teaching operational thinking and interpersonal behaviour driven by empathy and personal values. The fundamental assumption of a preoperative cognitive style in chronic depressed patients is supported by one study,[31] demonstrating that preoperative thinking is more pronounced in patients with chronic depression than in patients with episodic depression and healthy volunteers. In the Research Evaluating the Value of Augmenting Medication with Psychotherapy study, an RCT with over 800 depressed patients, CBASP, brief supportive psychotherapy and optimized pharmacotherapy were equivalent as augmentation strategies. [32] The study has been criticized because of potential methodological problems. In particular, only those patients were included who had consented to a pharmacotherapy-only study and had not achieved remissio