Efficacy of the third wave of behavioral therapies: a systematic review and meta-analysis

Author:
OST Lars-Goran
Journal article citation:
Behaviour Research and Therapy, 46(3), March 2008, pp.296-321.
Publisher:
Elsevier Science

Third wave cognitive-behavioural therapies (CBTs) have developed over the past 20 years and include acceptance and commitment therapy (ACT), dialectical behaviour therapy (DBT), cognitive-behavioural analysis system of psychotherapy (CBASP), functional analytic psychotherapy (FAP) and integrative behavioural couple therapy (IBCT). This review identifies 29 randomised controlled trials of third wave therapies, covering ACT (13), DBT (13), CBASP (1) and IBCT (2). None were found for FAP. They are found to have used significantly less stringent research methods than RCTs of mainstream CBT treatments. The mean effect sizes for ACT and DBT are moderate in size, and none of the third wave therapies meets the American Psychological Association’s criteria for empirically supported treatments.

Extended abstract:

Author
OST Lars-Goran;

Title 

Efficacy of the third wave of behavioral therapies: a systematic review and meta-analysis.

Journal citation/publication details

Behavior Research and Therapy, 46(3), March 2008, pp.296-321.

Summary

This methodological assessment and meta-analysis of randomised controlled trials (RCTs) of four developments of cognitive-behavioural therapy (CBT) finds that their methodological quality is significantly lower than RCTs of mainstream CBT treatments. A meta-analysis finds them to be of moderate efficacy but none meet the American Psychological Association criteria for an evidence-supported treatment.

Context

In the past 15 years several variants of (or extensions from) CBT have been developed and share ‘a focus on mindfulness, acceptance, defusion, the patient’s values in life, relationships, the rationale for how the treatment works, and the client-therapist relationship’. Although attracting considerable interest, they have also been criticised for lack of a sound empirical basis and this review thus seeks to evaluate outcome studies on the five principal third wave therapies.

Methods

What sources were used?
PsycINFO and Medline were searched from 1985 to mid-2007, and the reference lists of relevant papers were checked.

What search terms/strategies were used?
The search terms covered the five therapies of interest: Acceptance and Commitment Therapy (ACT); Dialectical Behavior Therapy (DBT); Cognitive Behavioral Analysis System of Psychotherapy (CBASP); Functional Analytic Psychotherapy (FAP); and Integrative Behavioral Couple Therapy (IBCT). It appears that the abbreviations were searched as well as the full names.

What criteria were used to decide on which studies to include?
Eligible studies were published or in press in an English language journal, dealt with one of the target therapies and were based on the random allocation of participants to either treatment or control, or to two or more active treatments.

Who decided on their relevance and quality?
The author presumably conducted any necessary relevance assessment of the unreported initial yield of studies from the searches.

An amended version of a referenced quality assessment tool, specifically developed for psychotherapy outcome studies, was used to rate the methodological standard of the studies included in the review and is reproduced as Appendix A. As an additional (and innovative) methodological check, the studies were also compared against ‘twin’ RCTs of traditional CBT interventions published within a year in the same journal, or in one of the three principal CBT journals. The twin studies are listed in Appendix B. Any studies published by the author or by any of his co-workers were excluded as twin studies to avoid biased judgements.

Finally, the status of the therapies as evidence-based treatments was assessed using referenced criteria from the American Psychological Association.

How many studies were included and where were they from?
Twenty-nine RCTs were reviewed covering ACT (13), DBT (13), CBASP (1) and IBCT (2). No trials of FAP were identified.

How were the study findings combined?
The comparisons with the CBT studies and with the American Psychological Association criteria are descriptive, while meta-analysis is used to examine the efficacy and effectiveness of the third wave therapies. Details of the meta-analytic and other statistical procedures are given, and a degree of statistical knowledge is assumed on the part of readers.

Findings of the review

The comparison of the third wave and ‘twin’ CBT studies showed that the former were significantly less stringent, methodologically speaking, than the latter. Only half the ACT studies diagnosed their participants although this was done in all DBT, CBASP and CBT studies. In addition, the number of participants starting DBT studies was lower, and attrition rates higher, than in the CBT studies. Since most DBT studies focus on borderline personality disorder, for which there is no apparent shortage of patients, the author can find no obvious explanation for their relatively small size.

The third wave studies had lower mean scores than the CBT studies when subjected to the quality assessment scale, and this findings persisted for ACT and DBT studies after the year of publication and journal were controlled for. Lower scores were evident in half of the 22 items on the scale, including representativeness of samples, reliability and validity of outcome measures, assignment to treatment, therapist training and experience, checks for treatment adherence, statistical analysis and presentation of data, and clinical significance. While adherence to some of the quality criteria does ‘take a toll in the budget’, this is not the case for many of these (and other) items, and again there is no obvious reason why stringent procedures were not followed.

The meta-analysis of results from the third wave studies produced mean effect sizes in the moderate range for the two therapies with a reasonable number of studies: ACT (0.68) and DBT (0.58). However, none of the studies is methodologically good enough, according to the American Psychological Association criteria, to pass muster as an evidence-supported treatment (EST). One of the DBT studies comes close but lacks a second, methodologically sound RCT by a different investigating team. The CBASP and one of the two IBCT studies would have fulfilled the criteria had they conducted equivalence analyses.

Authors' conclusions

‘If the proponents of the third wave treatments want to see their therapies on the list of ESTs, which is a fair assumption, there are some suggestions they should consider when planning future RCTs.’ A list of 15 specific methodological recommendations, some of which have already been incorporated in some of the studies, is provided, together with specific suggestions for the individual therapies:

ACT should be compared with CBT for the most common psychiatric disorders such as depression, anxiety disorders and eating disorders.

DBT should be compared with psychodynamic therapy (the version with the strongest evidence base) for the treatment of borderline personality disorder. In respect of eating disorders it should be compared with Fairburn’s CBT, and in respect of depression with CBT or behavioural activation.

CBASP should be compared with CBT for chronic and other forms of depression.

FAP should be examined by good quality RCTs for the treatment of depression, and then for other common psychiatric disorders.

IBCT should be evaluated in good quality RCTs by researchers who are independent from the team that developed it.

Implications for policy or practice

None are discussed beyond those relating to future research.

Subject terms:
randomised controlled trials, behaviour therapy;
Content type:
systematic review
Link:
Journal home page
ISSN print:
0005-7967

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