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‘Third wave’ Therapies

Dialectical Behavioural Therapy (DBT) 


The development of ‘Third Wave’ Cognitive Behavioural Therapy (CBT) “target (s) the process of thoughts (rather than their content, as in CBT) to help people become aware of their thoughts and accept them in a non – judgemental way.” (Hunot et al 2013:2).

Linehan’s unsuccessful practice experience working with clients with borderline personality disorder (BPD) in the 1970’s, prompted a rethinking of established CBT techniques to better manage the frequent experiences of ruptures in the therapeutic alliance; clients presented with the challenge of establishing new behaviour patterns, often experienced this as threatening and judgemental (Little, 2011:16). In 1993, Linehan developed DBT to specifically address her work with women diagnosed with BPD and exhibiting suicidal behaviours (Ball, 2007).


DBT “combines change strategies from cognitive behavioural therapies with acceptance strategies adapted from Zen teaching and practice; it is a synthesis of both validation and acceptance of the patient on the one hand, with persistent attention to behavioural change on the other.” (Rizvi & Linehan, 2005:489). The focus of treatment is on building coping skills, acceptance of non- changeable life elements, recognition and building of sound behaviours, and enhancing interpersonal capacity (Hunot et al, 2013, Padilla, 2010).

Mindfulness Based Cognitive Therapy (MBCT), Mindfulness Based Stress Reduction (MBSR) and Acceptance and Commitment Therapy (ACT)


Mindfulness has been further introduced into the CBT framework to address relapse from depression through Mindfulness Based Cognitive Therapy (MBCT) and Mindfulness Based Stress Reduction (MBSR), both group based ‘skills training’ approaches to recognising negative thought patterns and feelings while developing behavioural response skills to manage the potential of relapse (Hunot et al 2013: Padilla, 2010). Acceptance and commitment therapy (ACT) places a focus on developing psychological flexibility, that via a position of acceptance, a valued path may be chosen, and commitment to change enacted; “ACT is as much a change -oriented strategy as an acceptance – oriented one, but change is focused on areas that are readily changeable.” (Hayes, 2004:23).


Recommended treatment comprises weekly group skills training, individual therapy, telephone support to continue required skill development and regular therapist meetings to address burnout, and to build capacity (Rizvi & Linehan, 2005:489; Burroughs & Somerville, 2013). Skills training encompasses psycho education, regulation of emotions, tolerance to stress, and improved management of the self, and interpersonal effectiveness (Rizvi & Linehan, 2005). There is an emphasis placed on regular meetings for clinicians to reduce burn – out and enhance capabilities in mindful practice (Rizvi & Linehan, 2005:489; Burroughs & Somerville, 2013).

Therapeutic relationship

The evidence of continued disruption to a sound therapeutic alliance, so apparent when working with BPD (Rizvi & Linehan, 2005; Little, 2011), triggered the development of DBT; the shift in focus brought about by a mindful frame of practice has had a significant influence. The practice of DBT validates the experience of the client without blaming (Rizvi & Linehan, 2005; Padilla, 2010), and requires from the therapist the qualities developed through mindful practice. Padilla states “that genuineness, nonpossessive warmth, and accurate empathic understanding are important qualities of a therapist in an effective therapeutic relationship … These qualities are similar to those proposed to be enhanced and possibly created by mindfulness practice.” (2010:12). Campbell & Christopher (2012) identify a clear link between positive client outcomes, strength of the therapeutic relationship, and the personal characteristics of the therapist, noting “that teaching mindfulness strategies is an effective way to improve the therapeutic relationship.” (2012:216). Although mindful practice is considered to be closely aligned to the concepts supporting the therapeutic relationship, the relationship, “has remained essentially unstudied in mindfulness – based interventions.” (Goldberg et al, 2013:937).


There is clear evidence of improved outcomes for clients with BPD and active suicidality (Burns & Nolen – Hoeksema, 1992; Wright, 2006; Hershall et al 2009; McMain et al 2012; Clarkin et al 2013). A Cochrane review of psychotherapies for the treatment of BPD by Stoffers et al (2013), identified DBT as effective in the treatment of emotional regulation, self – harming behaviour and identified improvement in functioning. There is evidence that DBT is being adopted into adult community mental health programs as the preferred treatment for BPD (Hershall et al 2009, Burroughs & Somerville, 2012), although reviews of these programs were not found in literature searches.

Efficacy among other diagnostic groups yielding a positive response to input from ‘third wave‘ therapies is identified; bipolar and substance abuse (Hershell et al 2009), schizophrenia via MBSR (Chien & Lee, 2013) and eating disorders (Rizvi & Linehan, 2005). Hunot et al (2013), in conducting a Cochrane review of ‘third wave’ therapies for treating major depression, noted that available evidence indicated an equality with CBT in effectiveness, however, the absence of available studies identified “the need for further studies of third wave CBT approaches to fully assess their comparative efficacy.” (2013:25).

Reference list

Ball, S. (2007). Comparing individual therapies for personality disordered opioid dependant patients. In, Journal of Personality Disorders; June 2007; 21, 3; ProQuest Nursing & Allied Source. pp. 305-321

Burns, D.D. & Nolen – Hoeksema, S. (1992). Therapeutic Empathy and Recovery From Depression in Cognitive – Behavioral Therapy: A Structured Equation Model. in, Journal of Consulting and Clinical Psychology, 1992, Vol. 60, No.3:441-449.

Burrows, T. & Somerville, J. (2013). Utilization of Evidenced based Dialectical Behaviioral Therapy in Assertive Community Treatment: Examining Feasibility. In, Journal of Community Mental Health, 49;25-32. Doi 10.1007/s10597-012-9485-2.

Campbell, J.C., Christopher, J.C. (2012). Teaching Mindfulness to Create Effective Counselors. In, Journal of Mental Health Counseling Vol. 34, No. 3, July, 2012. pp. 213-226.

Chien, Wai Tong & Lee, I.W.M. (2013). The Mindfulness – Based Program for Chinese Patients With Schizophrenia. in, Psychiatric Services, April 2013 Vol. 64 No.4:376-379.

Clarkin, J.F., Levy, K.N., Lenzeneger, M.F. & Kernberg, O.F. (2013). Evaluating Three Treatments for Borderline Personality Disorder: A Multiwave Study. in, FOCUS Spring 2013, Vol. XI. No. 2. pp. 269-276.

Goldberg, S.B., Davis, J.M. & Hoyt, W.T. (2013). The Role of Therapeutic Alliance in Mindfulness Interventions: Therapeutic Alliance in Mindfulness Training for Smokers. In, Journal of Clinical Psychology, Vol. 69(9), 936-950.

Hayes, S.C.(2004) Acceptance and Commitment Therapy and the New Behaviour Therapies. In, Linehan, M., Follette, V. M., & Hayes, S. C. (2004). Mindfulness and Acceptance : Expanding the Cognitive-behavioral Tradition. New York: Guilford Press. pp. 1-29.

Herschell,A.D., Kogan, J.N., Caledonia, K.L., Gavin, J.G. & Stein, B.D. (2009). Understanding Community Mental Health Administrators’ Perspectives on Dialectical Behavioural Therapy Implementation. in, PSYCHIATRIC SERVICES psychiatryonline.org July 2009, Vol. 60, No. 7. pp. 989-992.

Hunot, V., Moore, T.H.M., Caldell, D.M., Furukawa, T.A., Davies, P., Jones, H., Honyashiki, M., Chen, P., Lewis, G. & Churchill, R. (2013). ‘Third Wave’ cognitive and behavioural therapies versus other psychological therapies for depression (Review). In, The Cochrane Library, 2013, Issue 10. pp. 1-54.

Little, S.E. (2011). The Therapeutic Relationship in Dialectical Behavior Therapy: A Longitudinal Investigation in a Naturalistic Setting. Retrieved from, Marquette University epublications@marquette http://epublications.marquette.edu/cgi/viewcontent.cgi?article=1159&context=dissertations_mu 20.05.2014

McMain, S.F., Guimond, T., Streiner, D.L., Cardish, R.j. & Links, P.S. (2012). Dialectical Behavior Therapy Compared With General {sychiatric Management for Borderline Personality disorder: Clinical Outcomes and Functioning Over a 2 – Year Follow – Up. in, American Journal of Psychiatry 169:6, June 2012.

Padilla, A. (2010). Mindfulness in Therapeutic Presence: How Mindfulness of Therapist Impacts Treatment Outcome. Retrieved from ProQuest UMI 3413183 http://www.integrativehealthpartners.org/downloads/padilla%202010%20mfn%20presence.pdf 20.05.2014

Rizvi, S.L., & Linehan, M.M. (2005). Dialectical Behaviour Therapy for Personality Disorders. In, FOCUS, Summer 2005, Vol 111, No. 3:489-494

Stoffers, J. M., Vollm. B. M., Rucker, J., Timmer, A., Huband, N., & Lieb, K. (2012). Psychological therapies for people with borderline personality disorder (Review). In, The Cochrane Library, 2012, Issue 8.

Wright, J.H. (2006). Cognitive Behavioural Therapy: Basic Principles and Recent Advances. In, FOCUS, Vol. 4:173-178.