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A comparison between dialectical behavio

2014, VOL. 9, NO. 2
ISSN: 1555–7855
A comparison between dialectical behavior therapy, mode
deactivation therapy, cognitive behavioral therapy, and acceptance
and commitment therapy in the treatment of adolescents
Christopher Bass1, Jolene van Nevel2, and Joan Swart2
Clark Atlanta University and 2Walden University
The recent rapid proliferation of “new wave” treatments, also loosely referred to as the third wave cognitive-behavioral therapies, has renewed interest in their comparative performance, scientific validity, and theoretical and
methodological integrity. However, critics are also expressing concerns that these therapies are not well enough
supported and “getting ahead of the data”. This article engages the literature on a small selection of modern therapy
approaches, namely Mode Deactivation Therapy (MDT), Acceptance and Commitment Therapy (ACT), and Dialectical
Behavior Therapy (DBT), and more specifically compared to Cognitive Behavioral Therapy (CBT). On the one hand,
it challenges the assumption that third wave therapies in general, but more specifically in reference to MDT, ACT,
and DBT, have little new to offer by way of superior performance, often in reference to populations that are usually
deemed as difficult-to-treat in traditional approaches such as CBT. While, on the other hand, it investigates claims
that third wave treatments are more part of a CBT family of approaches rather than distinct treatments. It draws
from the conceptualizations, practices, and experiences of the respective developers themselves to argue for the
distinct value and prospects that these third wave therapies offer in terms of scientifically established treatment
outcomes. For example, it is difficult and unwise to dismiss the superior results that MDT has established in treating
severe multi-problem adolescents, a population that has inarguably an extremely high human and economic impact
in the long run. By an improved understanding and differentiation of the third wave therapies, their proliferation
can be accelerated without compromise to harness their potential more effectively and focused.
mode deactivation, acceptance and commitment, dialectic behavioral, cognitive behavioral, adolescent therapy,
third wave therapy
s so-called third wave therapies, Dialectical
Behavior Therapy (DBT) and Acceptance and
Commitment Therapy (ACT), alongside with
Mode Deactivation Therapy (MDT), are derivatives
of Cognitive Behavioral Therapy (CBT). (Classical
behavioral therapies are referred to as the first wave,
and classical cognitive therapies as the second wave.)
Currently these three types of therapy have been
showing an increased amount of success with adolescent youth who have been suffering from disorders
such as Conduct Disorder, post-traumatic stress
symptomology, and other mood disorders (Apsche,
DiMeo, & Kohlenberg, 2012; Apsche, Bass, & Backlund, 2012; Powers, Vörding, & Emmelkamp, 2009) .
Dialectical Behavior Therapy
DBT was developed in 1993 by Prof. Marsha
Linehan, who wanted to adapt CBT when she recognized the shortcomings of the approach with her
borderline personality disordered patients (Bayles,
Blossom, & Apsche, 2014). The main objective was
to accommodate those specific characteristics such
as extreme emotional reactivity and high sensitivity
to vulnerabilities like perceived rejection. DBT uses
a variation of CBT that teaches the patient specific
skills they will need to cope with stress, and to help in
regulating their emotions (Apsche, 2010). Since then,
it has been shown to be useful for treating a wide variety of presenting issues, including suicidal behaviors,
substance abuse, eating disorders, and depression
(Murphy & Siv, 2012; Dimeff & Koerner, 2007).
The main goal of DBT is to teach the individual the
skills that they will need to cope with stress (Apsche
& DiMeo, 2012). This gives them tools that they
will need to change their current negative coping
(Arch, Eifert, Davies, Vilardaga, Rose, & Craske,
2012). DBT gives skills that are needed to become
productive members of the outside community in
which the individuals live in and helps them to gain a
positive perspective on value and acceptance of their
personal struggles, and enhances them for positive
change (Apsche, Siv, & Matteson, 2005).
A downfall to applying CBT elements in the DBT
methodology is that since its nature is to constantly
challenge the emotions of the individuals it is
making it hard for them to accept their beliefs as
real and reasonable. As such, they could perceive
that others view their emotional pain as not real and
an attempt to get attention, when, in fact, they are
truly suffering and experiencing emotional pain. A
positive of CBT elements in the DBT approach is that
it provides a way of acknowledging the experience
of their real pain (Apsche, Siv, & Matterson, 2005).
It is also reassuring that their current maladaptive
behavior actually makes sense and shows them
that they should change this way of coping, while
helping them find a more positive way of coping
with their problems that in the end will be healthier
for their well-being and mind set (Bayles, Blossom,
& Apsche, 2014). Furthermore, DBT uses CBT principles to form a bond between the patient and the
therapist so that they can work together to resolve
the problems and provide the patient new ways of
accepting what is causing them stress and to help
them change in a positive manner.
„„ Acceptance and commitment Therapy
mechanisms into positive ones that will help them
to regulate their emotions and improve relationships
with others around them (Apsche, 2010). It will then
teach the individual the skills that are needed to cope
in a positive manner to stress, regulate their emotions,
and to help them improve relationships with other
such as for adolescents their parents and other family
members. There are four key components that make
DBT successful; (a) cognitive behavioral theoretical
framework, (b) validation, (c) dialectics, and (d)
radical acceptance (Bayles, Blossom, & Apsche, 2014).
DBT uses dialectics which applies the concept that
everything is made up of opposites and the change
that happens is when one opposing force is stronger
than the other. This has three basic assumptions, first
being; all things are interconnected. Second, change
is constant and inevitable. Third, the opposites
can be integrated to form a closer approximation
(Apsche, 2010; Murphy & Siv; 2012, Apsche, DiMeo, & Kohlenberg, 2012). Today DBT is mainly
used with individuals who present strong urges to
harm themselves and or who have self-destructive
behavior (Apsche, DiMeo, & Kohlenberg, 2012).
This is one reason why this has been successful in
adolescents, particularly young males. DBT also
encourages acceptance and change. The acceptance is
unconditional and change is brought about through
the direct change of thoughts in a positive manner
(Apsche, DiMeo, & Kohlenberg, 2012).
DBT has been shown to improve behavior in three
strong areas that disordered adolescents typically
need help in improving: (a) lack of the needed behavioral coping skills, (b) accepting reality as it is,
and (c) maintaining strong commitment to change
Acceptance and Commitment Therapy (ACT), alongside Mode Deactivation Therapy (MDT), Cognitive
Behavioral Therapy (CBT), and Dialectical Behavior
Therapy (DBT), are all considered to belong to the
third wave of cognitive-behavioral therapies (Apsche,
2010; Zettle, 2012). The main goal of ACT is to help
the patient to stay aware of their private memories,
thoughts, and feelings without the need to change
or avoid them (Apsche, 2010; Ruiz, 2010; Jennings,
Apsche, Blossom, & Bayles, 2013). Alike MDT and
DBT, ACT also uses mindfulness techniques to gain
acceptance, commitment and positive behavioral
change. ACT therefore uses parts of CBT that focus
on cognition, and then allows the adolescent to
change the focus from challenging or controlling to
accepting the negative thoughts or emotions instead
of rejecting them (Jennings, Apsche, Blossom, &
Bayles, 2013). ACT then guides the adolescent in
separating the negative thoughts and behaviors in
order to change them into positive ones with the use
of mindfulness principles.
Mindfulness in ACT is the building bridge between
the collaborative relationship between the patient
and therapist (Jennings, Apsche, Blossom, & Bayles,
2013). Mindfulness in ACT is used to defuse language,
increase awareness, and to understand the self as
the observer of thoughts, feelings and experiences
(Romanoff, 2012). Mindfulness also helps the adolescent in this therapy approach to commit to taking
action in change. ACT uses defusion to separate
words from emotions (Ruiz, 2010). In ACT, cognitive
defusion techniques are applied in an attempt to
alter undesirable functions of thoughts and other
private events instead of denying their existence.
Table 1. Comparison between CBT, ACT, DBT, and MDT
Basic philosophies
Faulty thinking lead to disturbances
which is corrected by learning
Mixed acceptance, mindfulness,
commitment & behavior change
Combines CBT with Buddhist meditative
Childhood experiences lead to core
beliefs, which may lead to dysfunctional behavior
Key concepts
Problems rooted in childhood but
reinforced by present thinking and
core beliefs
Problems rooted in experiential
avoidance & cognitive entanglement
Emphasize psychosocial aspects
to manage arousal levels by
support-oriented, cognitive-based &
collaborative therapy
Focus on processes between
experiences, beliefs, modes/schemas,
thoughts, and behavior
Goals of therapy
Confront faulty beliefs and change
automatic thinking
Guides to contact with self-as-context;
Accept & choose alternative
Stabilizing, achieve behavioral control &
non-traumatic experiencing
To realign beliefs via modes to promote
healthier thoughts and behavior
Teacher-student and directive
Empowering & accepting
Ally with uncon-ditional acceptance
Collaboration as team is key
Structured cognitive, behavioral &
emotive techniques
Teaches to notice, accept & embrace
problem events
Learn skills of mindfulness,
interpersonal effectiveness, emotional
regulation & distress tolerance
Identify beliefs and associated fears,
and functional alternatives. Reinforce by
Wide range of Axis I disorders
Wide range of Axis I disorders,
addictions, compulsive behaviors, pain
BPD, mood disorders, sexual trauma,
chem. dependency
CD & complex comorbidity of male
youths 14-17
Client dependency, not confrontational,
structured, little focus on past
Does not address underlying cognitive
processes and origin of core beliefs
Treatment stability, client expectations &
differential effectiveness is questioned
(Scheel, 2000)
May be seen as confrontational; limited
independent validation; limited target
Empirical support
Extensive (137k ref. on Google Scholar)
Limited (219 ref.)
Low-Modest (669 ref.)
Limited (130 ref.)
Modest to good depending on
Low-Modest (d range 0-0.6)
Low-Moderate (avg d 0.2) (Kriem,
Kroger, & Kosfelder, 2010)
Good with target populations (avg d
Therapeutic relationship
Thereby, the unpleasant thoughts and feelings are
placed in their proper context where their impact
is diminished. Patients are encouraged to observe
their thoughts and emotions dispassionately and
objectively, without attaching them as reified parts
of their self. In essence, ACT helps patients “connect
with a transcendent, compassionate sense of self that
is bigger than our constructed identity or self-made
concepts (Romanoff, 2012, p. 134).
By using the philosophy of functional contextualism in ACT it helps to analyze the specific behaviors
that are causing the maladaptive behavior in terms
of their specific function in a very discrete context
(Arch, Eifert, Davies, Vilardaga, Rose, & Craske,
2012). In functional contextualism, psychological
events—thoughts, feelings, and behaviors—are
emphasized by focusing on manipulable variables
in their particular context at the time. As such,
functional contextualism has been developed to
help in clarifying psychological issues that continually remain foggy or unclear but are at the root of
the individual’s problematic behavior (Romanoff,
2012). This is used through the means of prediction
and influence. In the ACT paradigm, the patient’s
thoughts and feelings are not seen as being correct
or incorrect but rather as useful in understanding
and changing life to in order to experience more
value and satisfaction (Ruiz, 2010).
„„ Mode deactivation therapy
Mode Deactivation Therapy (MDT) is one of the
most recent types of therapy in treating aggression
and conduct disorder among juvenile adolescent
males. This therapy was developed by Dr. Jack
Apsche in the late 1990’s to overcome the limitations
of CBT with disturbed multi-problem adolescents
who were diagnosed with conduct disorders and
aggressive behavior (Apsche, 2010). Adolescents
with similar psychopathology are unable to override
the automatic responses that come along with their
emotional regulation. Therefore, at the center of the
MDT methodology is assessing and reconstructing
the core beliefs by way of Aaron Beck’s (1996)
theoretical constructs of modes (Apsche, 2010),
where modes are powerful sub-organizations of
one’s personality. According to Beck the modes
are constructed of four interconnected networks,
consisting of (a) cognitive (b) affective (c) motivational and (d) behavioral components (Apsche,
2010; Beck, 1996). This was originally developed to
be a proactive strategy in the response to trauma
and abuse (Beck, 1996). The main goal of this
therapy approach is to work together with the
youth in collaboration to help in discovering how
to change their current maladaptive behavior from
being socially unacceptable to being acceptable
with normal healthy responses to trauma and stress
(Bayles, Blossom, & Apsche, 2014). As such, MDT
has then shown to be very effective in the reduction
of physical and sexual aggression among aggressive
male adolescents (Apsche, 2010).
To understand MDT it is important to know what a
mode is and how it is used in the MDT methodology.
As briefly mentioned before, the modes in MDT
consist of four integrated networks that work together
to provide a proactive response to traumatic and
abusive experiences, with (a) cognitive, (b) affective,
(c) motivational and (d) behavioral components (Apsche, 2010, Apsche, Ward, & Evile, 2003). The youth
who best benefit from this therapy are those who are
to be considered to be emotionally charged, have
maladaptive behaviors, and “fly off the handle” (gets
enraged, angry) too quickly in reaction to perceived
threats. MDT utilizes mindfulness techniques to help
improve self-regulation. Mindfulness is described in
MDT by one being fully aware and accepting oneself
as you are in the moment without judgment (Apsche,
2010, Bayles, Blossom, & Apsche, 2014).
MDT helps patients to notice that the influx of
emotions can be better used in other positive ways,
just like in DBT. This therapy concentrates on these
strong emotions of fear, rage, and anxiety and teaches
adolescents how to overcome their negative urges
and attachments (Apsche, Ward, & Evile, 2003). The
use of MDT with this population is viewed as a positive therapy. Dr. Apsche has found that traditional
CBT can be too judgmental and intrusive on the
adolescent’s emotions. When working with these
adolescents with severe and aggressive behavior
problems, he has found that CBT caused them to
regress from the progress that was made with MDT,
and increased their resistance to therapy (Apsche,
2010). But, through the application of MDT, the
adolescents are gaining trust with the therapist and
have opened up to different and positive pathways
of coping. This can be solidified by the use of the
concept unique to the MDT methodology known
as “validation, clarification and redirection” (VCR)
(Apsche, 2010). VCR is used to provide the adolescent with tools and guidance to find their own
unconditional acceptance and validate their learning
experience (Apsche, 2010).
Therefore, unlike CBT, MDT accepts the adolescent’s
beliefs as a truth no matter how irrational it may
seem to others (Bayles, Blossom, & Apsche, 2014).
This helps in forming the strong bond that is needed
between the therapist and the adolescent. It also helps
in the validation of what the adolescent believes to
be the truth and what is the actual truth, and helps
them to see the difference between what they have
made up to be true and what is true. In a way it
lifts the dark cloud and provides a clean window
in to the truth of their current reality (Jennings,
Apsche, Blossom, & Bayles, 2013). By doing this
over all MDT helps the adolescent to discover who
they really are and how to accept it in the context
of their current environment.
„„ Comparison between MDT, DBT, and CBT
On the surface, it may seem that there is not that
much of a difference between MDT and DBT. Both of
these therapies have been proven as effective ways to
increase positive social change in these multi-problem adolescents. However, one difference is that MDT
does not utilize CBT principles to the same extent,
because the inherent disputation of their beliefs,
thoughts, and feelings in the CBT approach causes
the youth to regress from the progress what was made
with MDT and DBT therapy (Murphy & Siv, 2012).
On comparison of the treatment outcomes of MDT
versus CBT, MDT has been shown to provide superior
results in dealing with aggressive and multi-problem
adolescents, and is significantly more effective in
achieving treatment goals. As such, MDT has been
developed as an derivative of CBT in order to help
find a reliable method that is better suited for treating
adolescents with multiple issues while managing
their typical resistance to treatment (Apsche, 2010;
Apsche, Bass, & DiMeo, 2011). Furthermore, when
MDT is compared to CBT, it is also more effective in
decreasing severe and life-interfering behaviors such
as physical aggression and self-harm (Apsche, 2010;
Swart & Apsche, 2014).
Both ACT and DBT utilizes mindfulness as a core
concept to facilitate change. Although the initial
conceptualization of MDT did not include explicit
mindfulness techniques, it was added in the early
2000s in an adapted form that was suitable for
MDT’s adolescent target population. As such, the
exercises were shortened, simplified, and focused on
breathing, visual concentration, mindful walking, and
guided imagery that was brief, effective, and within
the adolescent’s ability (Apsche & Jennings, 2013),
whereas traditional adult programs for mindfulness
training have prohibitive time demands (Carmody
& Baer, 2009). Furthermore, DBT incorporates some
of the training skills aspects of CBT in order to teach
the adolescents how to change their behaviors and
learn new and more efficient ones. Using these
therapies together has given adolescent youth the
opportunity to change their maladaptive behaviors
and poor coping mechanisms while still accepting the
truth and not discouraging or completely changing
their belief system (Apsche, Bass, & Backlund, 2012;
Swart & Apsche, 2014).
Also, ACT and MDT both address the adolescent’s
avoidance of difficult and painful thoughts and emotions (Apsche, 2010). This is achieved by using both
cognitive and emotional defusion, mainly through a
process where adolescents teach themselves how to
anticipate and avoid painful stimuli or triggers. ACT
and MDT both have deep roots in the aspect of using
mindfulness. As briefly mentioned before, MDT’s
mindfulness techniques are specifically designed
for use with adolescents. MDT and ACT also use the
acceptance of one’s self as they are in the moment,
and progressing or moving forward with these
particular emotions and accepting them as they are
without judgment or attachment (Apsche, 2010;
Bayles, Blossom, & Apsche, 2014). Throughout ACT,
MDT, and DBT the principle of validation is used to
encourage positive behavior changes by allowing the
individuals to accept being non-judgmental of their
emotions. These three therapies have been proven
to show increasing positive change in adolescents.
Although each of these therapies use selected aspects
of CBT, each applies a distinct focus to cause this
change, encourage a strong therapist-patient bond,
and decrease treatment resistance and drop-out.
Mostly, with the exception of traditional CBT, third
wave therapies share the principles of mindfulness
and acceptance, and although the basic philosophies, principles, and goals may overlap, there are
subtle differences that arose from their respective
theoretical underpinnings and focus on a specific
target population (see Table 1). Also evident from
Table 1 is that these subtle—but sometimes more pronounced—differences are mostly in the manner that
dysfunctional cognitions are approached (disputation
versus acceptance), orientation to the past or present,
emphasis on experiential avoidance, philosophy
of emotion regulation (antecedent-focused versus
response-focused), goal-orientation (behavioral
or cognitive), and focus on function compared
to content of psychological events (i.e., thoughts,
feelings, and emotions). The applications in terms
of target population and/or presenting problems are
also varied, as are the availability of an evidence base,
and reports of efficacy.
Although there is a rapidly growing evidence
base to support third wave therapies empirically,
there is no conclusive support for a general and
unconditional assumption that any or all third
wave therapies are superior to classical Cognitive
Behavioral Therapies. However, specific therapeutic outcomes and attrition rates are distinctive in
particular patient populations (Kahl, Winter, &
Schweiger, 2012). Research of third wave therapies
have not yet reached the point of maturity where
component or mediation analyses have been able
to define—quantitatively or qualitatively—the effect
that different therapeutic elements have in mediating
or moderating the outcome. Nevertheless, there are
subtle, and sometimes more definitive, differences
between traditional CBT and therapies such as ACT,
DBT, and MDT. The most prominent and meaningful of these are briefly discussed in an attempt to
delineate the particular therapies in more detail. It
is important to reemphasize that some approaches
that are often included with the third wave, are not
deemed as such by their developers. One such a
therapy is Dialectical Behavior Therapy (DBT). The
developer, Marsha Linehan considers DBT to be an
extension of CBT that integrates acceptance strategies
instead of an authentic theoretical deviation thereof
(Hofmann, Sawyer, & Fang, 2010). In fact, CBT and
other third wave therapies can be considered as a
family of interventions that are based on the notion
that “modifying maladaptive behaviors can lead to
a decrease in emotional distress and problematic
behaviors” (p. 702). However there are important
philosophical and procedural differences among them.
1. Theoretical roots: Both CBT and DBT are based on
the basic premise of the causal interaction between
cognitions, behaviors, and emotions. According
to developer Dr. Stephen C. Hayes, ACT is not an
extension of the CBT model, but a reformulation
of Skinnerian radical behaviorism that links responding with reinforcement according to operant
conditioning principles, which are incorporated
with acceptance and mindfulness. The developer
of MDT, Dr. Jack Apsche, has purposefully taken a
step back by adopting elements of psychoanalytic
object relations and Piagetian schema development
into the frame of Beck’s cognitive theory together
with acceptance and mindfulness.
2. Resistance to treatment, dropout, and attrition:
Despite claims that the newer third wave therapies
outperform CBT, several factors have to be taken into
account. Firstly, the evidence base for ACT, DBT, and
MDT are much smaller, although expanding rapidly.
Secondly, the development of third wave therapies
were based on specific target populations and the
cognitive content specific to their issues where CBT
has been deemed ineffective. Nevertheless, third
wave therapies are reporting great success with their
target populations in terms of resistance to treatment—a common problem in many difficult-to-treat
groups and countered by the acceptance approach
common to third wave therapies—dropout, and
attrition (Kahl, Winter, & Schweiger, 2012; Jennings,
Apsche, Blossom, & Bayles, 2013).
3. Durability and relapse: The same limitations
relating to a smaller evidence base apply that were
previously discussed. Here, the third limitation is
the relative recentness of the third wave therapy
conceptualizations and practice, which only started
in the late 1980s and 1990s. However, indications
are that these approaches also outperform CBT
for their respective target groups with respect to
durability of treatment effect and relapse rate (Bach
& Hayes, 2002; Linehan, Comtois, Murray, Brown,
Gallop, Heard,…Lindenboim, 2009), although
some results to the contrary were also reported
(Forman, Shaw, Goetter, Herbert, Park, & Yuen,
2012). Specifically pertaining to adolescents with
severe multi-problem behaviors, MDT research
found a significant improvement in behavioral
treatment effects that markedly outperformed the
CBT-based TAU control groups, and was sustained
to a follow-up period of at least 18 months (Apsche,
Bass, & Siv, 2006a; Apsche, Bass, & Siv, 2006b).
4. Evidence base: As mentioned before, the evidence
base of ACT, DBT, and MDT are much smaller
compared to CBT. Where CBT is explored in hundred-thousands of peer reviewed publications, ACT,
DBT, and MDT continue to lag significantly in this
regard (see Table 1). However, the research pool of
these newer third wave therapies are increasing at
an exponential pace.
5. Past orientation: With the exception of MDT, CBT
and third wave therapies focus exclusively in the
present moment and attempt to modify behavior
by disputing or otherwise addressing related
thoughts and feelings in real time. MDT has adopted a different focus by exploring past experiences in
conjunction with problematic psychological events
in the present. The premise is that by incorporating
a psychoanalytic component in context with the
present situation, the improved insight will bring
about a more effective and durable change effect.
6. Disputation and acceptance: In CBT, dysfunctional
thoughts, feelings, and behavior are disputed
as “bad” and attempts are made to change their
contents or deny their existence altogether. Newer
therapies, including ACT, DBT, and MDT, have instead incorporated the concept of radical acceptance,
where psychological events are accepted and not
judged while attachment and identification with it
are discouraged. Instead a decentered perspective
of thoughts and feelings are fostered, which are
“de-linked” from the concept of self or reality.
7. Mindfulness: Mindfulness has been defined as “the
awareness that emerges through paying attention
on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by
moment” (Hofmann, Sawyer, & Fang, 2010, p. 703).
CBT in the traditional sense does not utilize mindfulness techniques and—other than mindfulness-based
interventions—focus on a reflexive rather than reflective response to stressful situations and negative
emotions. The presumption is that active awareness
suppresses the default mode network of the brain
at wakeful rest, thereby avoiding rumination of
negative thinking that tends to become a self-perpetuating cycle. ACT and DBT tend to base mindfulness
techniques on traditional Buddhist meditative
practices, while MDT favors basic mindfulness
exercises that are easy and quick for adolescents to
learn, and find non-threatening—as “multiple paths
to mindfulness” (Jennings & Apsche, in press).
8. Procedural: There are various procedural differences evident between and among CBT and third
wave therapies. In general, CBT tend to be more
structured versus the eclectic largely procedural
approach of most third wave therapies. It is
interesting to note that this has also been raised
as a concern in terms of theoretical and therapist
“drift” from established frameworks and protocols that tend to reduce cost effectiveness and
integrity of the intended methodology. Of these,
with a structured and sequential assessment and
treatment process, MDT is considered to be the
most procedurally strict (Swart & Apsche, 2014).
9. Behavioral strategies: Where traditional CBT
focuses on changing or modifying psychological
events that people experience in order to achieve
desired behavioral outcomes, third wave therapies
instead focus on changing the function of these
events. Furthermore, CBT emphasizes experiential
avoidance strategies instead of acceptance as ACT
and MDT does. As such, CBT attempts to “identify
and refute maladaptive cognitions with the goal
to change the emotional response associated with
them” (Hofmann, Sawyer, & Fang, 2010, p. 706),
whereas ACT and MDT creates and awareness
an acceptance of problematic thoughts, feelings,
and behavior as they occur. ACT is therefore
response-focused compared to CBT that is antecedent-focused. MDT seems to be somewhere
between these two, with a primary focus on present
events, but a secondary focus on underlying past
experiences to identify and anticipate triggers that
can assist with emotion regulation.
10. Techniques: Although there does not seem to be
major differences in the principles and goals of
CBT, DBT, MDT, and ACT, Brown, Gaudiano, and
Miller (2011) contend that differences are mostly
evident in the actual strategies and techniques
that are applied. We have already mentioned that
third wave therapies utilize more mindfulness
and acceptance techniques, but Brown and her
colleagues also reported a greater reported use
of existential-humanistic techniques to address
the challenges of everyday life in a balanced
and holistic way, although the experiences and
influences of the past are given much less emphasis than those in the present. Functional
contextualism has special importance; techniques
are functionally defined rather than topographically distinguished as from where it originates.
Exposure techniques are more commonly used
in third wave therapies, which illustrates the
emphasis on traditional behavior strategies in lieu
of cognitive restructuring techniques, although the
latter is prominently employed in the “Validation,
Clarification, and Redirection” (VCR) step that is
a unique process component in MDT. Hereby the
client becomes aware of dysfunctional cognitions
and their underlying beliefs, while developing
and trying out functional alternatives “one small
step at a time”, on a continuum.
Therefore, in general, there are perhaps more
similarities than differences between and among
CBT and third wave therapies than typically assumed,
although the subtle differences are purposely directed
at target populations and conditions, which amplify
their functional effect. The concepts of mindfulness
and acceptance are common to this wave therapies,
while the past is for the most part discounted, with
the exception of MDT, in which past experiences
are explored in relation to the experience of their
remnants in present psychological events.
„„ The future of third wave
therapies, in particular MDT
The concerns that we have briefly mentioned before
need to be more thoroughly examined, with special
emphasis on the effect that it has on treatment effectiveness, reliability, and generalizability. Of particular
interest is the validity of the underlying scientific and
theoretical framework, as well as how each therapy
approach embody the principles conceptually and in
actual practice. It would also be extremely worthwhile
to understand and differentiate the mediating and
moderating influence of each process component
on the change effect and therapeutic outcomes.
Thereby, we can come to quantitatively appreciate
to what extent and how process elements such as
mindfulness techniques contribute to change. Such
studies have already been conducted for CBT, but
are still lacking in the third wave therapies. It will
also contribute to an understanding of how and why
CBT reportedly fail for certain populations, while
third wave therapies seem more effective to a lesser
or greater extent. We presume, with good reason,
that each emotional disorder are characterized by
cognitive content that is specific to that disorder,
but to what degree can protocols be tailored and/
or generalized to improve treatment for the same,
other, and broader populations? The developers of
ACT (Stephen Hayes), DBT (Marsha Linehan), and
MDT (Jack Apsche) has already done a sterling job
to promote and establish the evidence base of their
respective approaches. Now, continued effort is
required to better understand and appreciate the
differences in mechanisms and applications of these
respective therapies. We do not necessarily need
more emerging themes, but maybe a unified and
flexible application instead that remains in the realm
of scientific principles and validity.
As we have compared CBT, MDT, ACT, and DBT,
it hopefully became evident that differences are
for the most part not theoretically or procedurally
irreconcilable, in fact many ideas and principles seem
perfectly compatible. For example, Mode Deactivation Therapy (MDT) is a synthesis of elements from
DBT, CBT, ACT, mindfulness, and psychoanalysis
that was adapted for an adolescent population that
was traditionally considered as difficult-to-treat. In
various studies already it has shown remarkable
results while holding up under stringent scientific
scrutiny of its theory and practice. MDT, “the third
wave movement”, and psychotherapy as a whole, can
greatly benefit from statistically sound evidence of
the influence that respective process components
exert on the overall treatment effect.
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