The International Journal of Behavioral Consultation and Therapy ©2011, All rights reserved. 2011, Vol. 7, No. 1, 55–67 ISSN: 1555 - 7855 Evaluating Acceptance and Commitment Therapy: An Analysis of a Recent Critique Brandon A. Gaudiano Department of Psychiatry & Human Behavior Alpert Medical School of Brown University Psychosocial Research Program Butler Hospital Acceptance and commitment therapy (ACT) is a newer psychotherapy that has generated much clinical and research interest in recent years. However, the approach has begun to receive strong criticism from proponents of traditional cognitive-behavioral therapy (CBT). Hofmann and As- mundson (2008) recently compared and contrasted ACT and traditional CBT. They concluded t hat ACT’s criticisms of traditional CBT are inaccurate; both ACT and CBT can be understood using a similar theoretical model; and there is no evidence that ACT represents a “third wave” of behavior therapy, as is sometimes claimed by its proponents. In the current article, I further analyze Hofmann and Asmundson’s critique of ACT to determine its evidential merit and to attempt to clarify potential points of misunderstanding between CBT and ACT proponents. Keywords: acceptance and commitment therapy, cognitive behavior therapy, psychotherapy research Acceptance and commitment therapy (ACT) is a novel fusion is defined as “the tendency of human beings to live in acceptance/mindfulness-based behavioral treatment that has a world excessively structured by literal language” (Strosahl, been increasing in popularity in recent years. A detailed de- Hayes, Wilson, & Gifford, 2004, p. 39). For example, when scription of ACT theory and technique is beyond the scope a person is fused with a thought (“I am depressed”), he/she of the current article, and thus it will only be summarized is experiencing that thought literally (“I” = “depression”). briefly here. Readers are referred to other books and arti- This cognitive fusion permits the literal content of thinking cles that provide more detailed descriptions (Hayes, 2004a, to dominate over a person’s behavior (“I can’t go to work to- 2004b; Hayes, Barnes- Holmes, & Roche, 2001; Hayes, Lu- day because I am depressed”). Cognitive fusion also fosters oma, Bond, Masuda, & Lillis, 2006; Hayes & Strosahl, 2004; experiential avoidance, which is defined as “the attempt to Hayes, Strosahl, & Wilson, 1999). escape or avoid the form, frequency, or situational sensitiv- ACT stems from a philosophy of radical behaviorism. ity of private events, even when the attempt to do so causes The approach itself is rooted in a specific theoretical model, psychological harm (Hayes et al., 2004, p. 27). When en- called Relational Frame Theory (RFT) (Hayes et al., 2001), gaged in experiential avoidance, the person attempts to avoid which was developed to provide an updated behavior analytic or suppress undesirable private material such as thoughts, account of language that expands upon the previous work of memories, emotions, and bodily sensations as if they were B. F. Skinner. In general, ACT can be described as combin- inherently harmful, even though doing so can paradoxically ing acceptance and mindfulness strategies with overt behav- worsen these problems in the long-run (Wenzlaff & Wegner, ior change efforts to improve what its creators call psycho- 2000). The co-processes of fusion and experiential avoid- logical flexibility (Hayes et al., 1999). Psychological flex- ance result in the narrowing of a person’s behavioral reper- ibility is defined as “the ability to contact the present mo- toire (i.e., psychological inflexibility), which is believed to ment more fully as a conscious human being, and to either lead to and maintain a wide spectrum of psychopathological change or persist when doing so serves valued ends” (Hayes, behaviors. ACT targets six core processes for psychological Strosahl, Bunting, Twohig, & Wilson, 2004, p. 5). In other flexibility: promoting acceptance of distressing internal ex- words, healthy psychological functioning is proposed to be periences, fostering cognitive de- fusion so the literal content related to a person’s ability to adaptively respond to changing of thought does not dominate over a person’s behavior, prac- environmental contingencies. In contrast, psychological in- ticing awareness of ongoing experience in the present mo- flexibility or rigidity is theorized to be the result of what ACT ment, establishing a stable sense of self that is broader than calls cognitive fusion and experiential avoidance. Cognitive merely its evaluative content, developin g personal valued life directions to guide behavior, and committing to actions that are consistent with these personally chosen values. This work was supported in part by grants from the National In- Various psychotherapeutic techniques, many of which stitute of Mental Health (MH076937) and NARSAD: The Mental are inspired by or borrowed from other approaches to psy- Health Research Association. chotherapy (e.g., humanistic, gestalt), are used to address 55 56 GAUDIANO psychological inflexibility. In particular, ACT makes heavy thors: (1) responded to Hayes and colleagues’ previously use of metaphors, logical paradoxes, and experiential exer- published criticisms of traditional CBT; (2) proposed that cises, as well as more traditional behavioral techniques (e.g., Gross’ (2001) emotion regulation model can be used to ex- behavioral activation, exposure). The goal of these strate- plain both ACT and CBT; and (3) rejected the argument that gies is to improve psychological flexibility by fostering ac- ACT represents a “third wave” of behavior therapy. Each of ceptance of internal states of distress and cognitive defusion these topics is discussed in detail below to better understand from problematic language-based processes. the concerns expressed by critics and to attempt to determine Initial research on ACT suggests that: (1) Psychologic al their actual evidential merit. inflexibility is related to diverse indices of psychopathology as predicted. (2) ACT has been shown to be potentially effi- cacious for a variety of clinical conditions based on prelim- AN ANALYSIS OF HOFMANN AND ASMUNDSON’S REBUT- inary trials. (3) Many of the specific components of ACT TAL TO HAYES ET AL.’ S CRITIQUE OF CBT show initial evidence of efficacy in experimental studies. (4) ACT appears to work at least partly through its hypothesized In an attempt to differentiate ACT from traditional CBT, mechanisms of action; although formal statistical mediation Hayes and colleagues (Hayes, 2004a; Hayes et al., 2006; has only been demonstrated in a few studies to date (Hayes Hayes et al., 1999) have offered critiques of traditional CBT et al., 2006). The aforementioned research is in addition to theory and technique. In their own review, Hofmann and numerous experimental studies conducted to date that sepa- Asmundson (2008) attempt to rebut many of Hayes and col- rately lend support for RFT, the underlying basic science re- leagues’ criticisms. First, I present the original criticisms search program that relate to the clinical application of ACT offered against CBT by Hayes and colleagues, followed by (Hayes et al., 2001). Hofmann and Asmundson’s rebuttals, and finally my analy- The ACT studies conducted to date lend support for many sis of these issues. important aspects of the approach, but most represent small pilot studies that have methodological limitations. Thus, in- Critique 1: CBT Is a Mechanistic Approach dependent replication trials using larger samples will be nec- essary to confirm these initial promising findings. However, Hayes et al. (1999) argue that CBT -based approaches hold the evidence to date appears moderately strong in support of certain underlying “mechanistic” philosophical assumptions, ACT at this stage of investigation. Recent meta- analyses of such that they promote the notion (sometimes implicitly) that ACT outcomes conducted in a wide-range of clinical popula- internal mental states are directly causal in relation to behav- tions indicate medium to large effect size differences versus ior. In contrast, Hayes et al. (2006) state that ACT is based comparison conditions (Hayes et al., 2006; Öst, 2008; Pow- on a pragmatic philosophy called functional contextualism, ers, Zum Vörde Sive Vörding, & Emmelkamp, 2009), which which “views psychological events as ongoing actions of the is consistent with the broader CBT literature. Contrary to whole organism interacting in and with historically and situ- some authors’ claims to the contrary regarding ACT’s empir- ationally defined contexts” (p. 4). Hayes et al. (1999) further ical status (see Öst, 2008), the American Psychological As- explain: sociation’s Division 12 (Clinical Psychology) recently inclu ded ACT for depression on its list of empirically-supported Some types of cognitive-behavioral therapy, for treatments, concluding that it has “moderately strong” em- example, are based on a computer metaphor (as pirical support based on published clinical trials1. is much of cognitive psychology itself). Like a computer, humans are thought to store, ac- The increasing popularity of ACT in recent years has be- cess, and process information. In this view, the gun to draw the attention and scrutiny of proponents of tradi- task when dealing with an unworkable thought tional cognitive- behavioral therapy (CBT), many of whom is to change the form of the thought, just as a have expressed skepticism about the approach. In recent ar- computer may be changed by replacing memory ticles and book