Third-wave cognitive behavioural therapies
Also called contextual therapies, they are the most recent development of CBT. Rather than only trying to change what you think or feel, they work on your relationship with your thoughts and emotions, and on what you do with them. This is the framework I have specialised in most: above all ACT, mindfulness and DBT, which I integrate according to each person’s needs.
What are third-wave therapies?
In 2004, Steven C. Hayes used this name for a group of therapies born within the cognitive behavioural tradition that share the same outlook: what matters is not so much the content of a thought or emotion (positive or negative, true or false) as the function it serves in your life and the context in which it appears. That is why they are also called contextual therapies.
Three shared ideas
Changing the relationship, not just the content
A thought like “I’ll never manage” loses its power when you learn to see it for what it is, a thought, without having to argue with it or obey it.
Acceptance and mindfulness
Stopping the fight against unavoidable discomfort frees up energy. Paying attention to the present, with curiosity and without judgement, is a skill you can train.
Values and action
The goal is not only to reduce symptoms, but to help you build a life that is meaningful to you, even with some discomfort.
Three waves of cognitive behavioural therapy
The first wave, in the mid-20th century, is behaviour therapy: techniques based on the laws of learning, such as exposure or reinforcement. The second, from the 1960s and 1970s, brings in cognition with authors such as Aaron Beck and Albert Ellis: identifying and changing distorted thoughts. The third, since the 1990s, gives context its full place again and adds acceptance, mindfulness and values.
It is not that one wave replaces the previous one: exposure and cognitive restructuring remain very effective for many difficulties. Third-wave therapies broaden the tools available, which is why I combine them with classic CBT in an integrative approach.
The main contextual therapies
Several models are grouped under this name. The best known are:
Acceptance and Commitment Therapy (ACT)
Developed by Steven C. Hayes, it aims at psychological flexibility: staying in contact with the present and acting according to your values, even when difficult thoughts or emotions are there. It is my main approach.
Dialectical Behaviour Therapy (DBT)
Created by Marsha Linehan for people who find it very hard to regulate their emotions. It combines acceptance and change, and teaches concrete skills: mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness.
Mindfulness and Mindfulness-Based Cognitive Therapy (MBCT)
Mindfulness training, developed in a clinical setting by Jon Kabat-Zinn, and its integration into cognitive therapy to prevent depressive relapse (Segal, Williams and Teasdale).
Behavioural activation
It helps you break the cycle of inactivity in depression, by gradually returning to activities linked to what matters to you.
Functional Analytic Psychotherapy (FAP)
It uses the therapeutic relationship itself as a space to observe and change relationship patterns.
Compassion-Focused Therapy (CFT)
Developed by Paul Gilbert, it works on self-criticism and shame by cultivating a kind attitude towards yourself.
I work integratively with the family of contextual therapies, with particular attention to ACT, mindfulness and DBT, in which I have received specific training.
ACT: getting out of the avoidance trap
When fighting discomfort makes it bigger
ACT starts from an observation: many psychological difficulties are maintained by our attempts not to feel what we feel. This is called experiential avoidance.
Discomfort shows up
An unpleasant thought, memory, emotion or sensation.
You try to control it
You avoid it, distract yourself, ruminate, or do something so as not to feel it.
Short-term relief
It works for a while, which is why you do it again.
Your life gets smaller
You give up important things and the discomfort comes back, often stronger.
The alternative offered by ACT is psychological flexibility, developed through six processes: acceptance (opening up to discomfort instead of fighting it), cognitive defusion (seeing thoughts as thoughts), contact with the present moment, self-as-context (not identifying with your thoughts), values and committed action.
DBT and mindfulness share this logic: accepting what cannot be changed in the moment, so you can change what is up to you.
What research says
Contextual therapies are supported by a growing number of studies, with different levels of evidence depending on the model and the difficulty:
Evidence for many difficulties
A review of meta-analyses (Gloster and colleagues, 2020) concludes that ACT is effective for anxiety, depression, chronic pain and addictions, among others. APA Division 12 rates its support for chronic pain as strong.
Emotion regulation and self-harm
It is the most studied psychotherapy for borderline personality disorder. The 2020 Cochrane review found benefits compared with usual treatment, with a level of certainty that is still low.
Preventing depressive relapse
An individual patient data meta-analysis (Kuyken and colleagues, 2016) showed that it reduces the risk of relapse. NICE recommends it for people in remission from depression.
Overall, studies show that these therapies are effective, but not that they are superior to classic CBT: they are a validated alternative or complement, not a replacement.
Towards process-based therapy
Hayes and Hofmann (2017) suggest moving beyond the competition between “waves” to identify which processes (avoidance, rumination, drifting away from your values…) maintain each person’s difficulty, and to choose the techniques that act on them best. This is the logic I try to work with.
How I integrate them
Assessment and formulation
We identify what keeps your distress going: avoidance, rumination, difficulty regulating emotions, drifting away from what matters to you…
Choosing the tools
Depending on your situation, we work with ACT processes, DBT skills, mindfulness practices or classic CBT techniques.
Practising in your life
Short exercises between sessions to bring the work into your daily life.
Reviewing and adjusting
Together we check what is working and adapt the plan.
Contextual therapies are not “just meditating” or “just accepting”: they always include an element of change and action.
Things to try today
Label your thoughts
Try saying to yourself “I’m having the thought that…”. This small change creates distance without arguing with your mind.
Three minutes of attention
Stop, notice your breathing, your body and what you are feeling, without trying to change it. Then go back to what you were doing.
Ask yourself what matters
In one area of your life (relationships, work, health), what kind of person do you want to be? Choose one small action in that direction.
Notice how intense your emotions are
Rate your emotions from 0 to 10 at different times of the day: it is the first step towards regulating them.
Gonzalo Garzo
Clinical psychologist · ACT, DBT and mindfulness · integrative approach
I have been a clinical psychologist since 2018, and I am also an anthropologist. For years I combined psychology with management positions (see my LinkedIn profile), before dedicating myself fully to clinical work.
I work with an integrative approach: CBT, third-wave or contextual therapies (especially ACT, DBT and mindfulness), EMDR and humanistic psychology, adapted to each person’s needs.
I have lived in several countries and I can support you in English, French or Spanish, online or in La Rochelle.
Frequently asked questions
Are they different from CBT?
They are part of it: they are its most recent developments. They share the rigour and scientific orientation of CBT, with a different emphasis on acceptance, context and values.
Does mindfulness have a religious dimension?
Although it draws on contemplative traditions, in clinical psychology it is used as attention training, without any religious dimension, and it has been studied scientifically.
Is DBT only for borderline personality disorder?
It was created for that, but its emotion regulation and distress tolerance skills now help many people whose emotions are very intense or hard to manage.
Does accepting mean giving up?
No. Accepting means stopping the fight against what you cannot control in the moment, so you can put your energy into what you can change.
Can it be done online?
Yes. ACT, mindfulness and DBT exercises adapt very well to video sessions and you practise them in your own environment.
Shall we talk?
Sources
- Hayes, S. C. (2004). Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behavior Therapy, 35(4), 639-665.
- Pérez Álvarez, M. (2014). Las terapias de tercera generación como terapias contextuales. Síntesis.
- Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A. & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44(1), 1-25.
- Gloster, A. T., Walder, N., Levin, M. E., Twohig, M. P. & Karekla, M. (2020). The empirical status of acceptance and commitment therapy: A review of meta-analyses. Journal of Contextual Behavioral Science, 18, 181-192.
- Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.
- Storebø, O. J. et al. (2020). Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews, 5, CD012955.
- Segal, Z. V., Williams, J. M. G. & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy for depression (2nd ed.). Guilford Press.
- Kuyken, W. et al. (2016). Efficacy of mindfulness-based cognitive therapy in prevention of depressive relapse: An individual patient data meta-analysis. JAMA Psychiatry, 73(6), 565-574.
- National Institute for Health and Care Excellence (2022). Depression in adults: treatment and management (NG222).
- Society of Clinical Psychology, APA Division 12. Psychological Treatments: Acceptance and Commitment Therapy; Dialectical Behavior Therapy for Borderline Personality Disorder.
- Hayes, S. C. & Hofmann, S. G. (2017). The third wave of cognitive behavioral therapy and the rise of process-based care. World Psychiatry, 16(3), 245-246.
This page is for information only and does not replace a professional assessment.