The Fourth Wave of Psychotherapies

The challenges associated with the latest group of psychotherapies.

Posted Apr 18, 2018

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John Peteet, in a paper currently in press in Harvard Review of Psychiatry, discusses the conceptual, practical, and ethical challenges of a “fourth wave” of psychological therapies.

The fourth wave—resting on a foundation of existential, humanistic, and spiritual/religious philosophies—comprises the likes of compassion focused therapy, loving-kindness meditation, meaning-focused and spiritually-informed treatments (e.g., pastoral therapy), and various strength-based and virtue-centered interventions (e.g., treatments that promote dignity, forgiveness, gratitude, hope, etc).

Unlike older interventions (e.g., psychodynamic or cognitive-behavioral therapy) and their sole concern with treating dysfunction, this latest wave of therapies also aims to increase one's general sense of well-being.

Conceptual vagueness

Peteet observes that this new group of therapies presents a number of unique challenges. For one, many of the concepts and the aims of these interventions remain vague.  

For instance, does meaning, in meaning-centered therapies, refer to “personal meaning or to a transcendent source of purpose and direction?” Similarly, what exactly do spirituality, gratitude, and dignity, signify?

A concept’s practical applications may also present difficulties, as might the measurement of its efficacy.

For example, how far should forgiveness be extended? And, in general, how should we measure the effectiveness of the fourth wave interventions—in “clinical terms” or perhaps in “terms descriptive of well-being”?

Value conflict

An even bigger challenge concerns value conflicts.  Which is why the author presents a detailed examination of the sources of value conflict: The patient, the therapist, and the treatment culture.


Peteet is concerned that, because of the power differential in therapy, patients’ values may be inadvertently influenced by those of their therapists. 

For instance, the therapist may unintentionally impose her values when she encourages her patient to forgive an abuser.

To reduce this risk, therapists need to be candid about the aims of therapy, work toward consensually established positive goals, and make sure that revealing their own values in therapy serves solely the purpose of benefiting their patients.


Fourth-wave therapies are unique in that they require the clinicians to call on their own worldviews to help define the aims of therapy. It is for this reason that clinicians’ values can be another source of conflict.

Therapists are likely to hold one of the following four worldviews:

1. Radical materialism refers to the view that all reality is reducible to material phenomena. Those committed to this view are likely to think of health solely as the absence of disease, and thus use only those treatments that aim to replace maladaptive responses with adaptive ones.  

2. Secular humanism, resisting the reductionist assumptions of radical materialism, assumes that evolution and human reason have given rise to values important for human flourishing and healing, values like autonomy, agency, and freedom.

Common therapeutic goals for a humanist clinician might include the reduction of suffering and the enhancement of mastery.

3. Pantheism is associated with the “spiritual but not religious” ideologies, with a vision of the world as the manifestation of an impersonal life force, and as a result, with valuing harmony between all parts of life.

Pantheist therapists are likely to stress techniques that are holistic (e.g., mindfulness), and ones that help the patient gain perspective and connect with a reality beyond the material world.

4. Monotheism, while in agreement with many of the above ideas, is unique in being based on a belief in a personal God. Depending on the monotheistic tradition, healing and flourishing can be seen as dependent on different aspects of one's personal relationship with the Maker.

To illustrate, a Muslim therapist might emphasize finding meaning through the cultivation of virtues inspired by God, ones like perseverance, courage, dignity, kindness, contentment, etc; a Christian clinician could be more inclined to stress the importance of love, acceptance, and forgiveness.


The treatment culture too can be a source of value conflict. Peteet observes that the legitimacy of an intervention is determined in a large part by governmental guidelines, insurance policies, professional codes of practice, and other regulations.

Given that the fourth wave interventions are less focused on deficit and disease, and more on growth and flourishing, an obstacle to their use is “criterion of medical necessity employed by payers.”  For example, spiritual crises may not be reimbursable unless they are considered “useful in the treatment of a DSM-5 disorder.”


Peteet ends by warning us that failing to “acknowledge the conceptions of human flourishing” can result either in the clinician influencing the patient “on the basis of unconscious personal bias, spiritual or secular,” or alternatively, in the clinician refusing to engage the “value-laden aspects of treatment because of a fear of exerting undue influence.”

The second alternative, of avoiding value differences and focusing only on symptoms of a disease and the symptom-focused treatment, though easier, “misses important opportunities to help...[the patient] grow.”


Peteet, J. R. (in press). A fourth wave of psychotherapies: Moving beyond recovery toward well-being. Harvard Review of Psychiatry. doi:10.1097/HRP.0000000000000155