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TheInternational Journal of Behavioral Consultation and Therapy ©2011,Allrights 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
Acceptanceandcommitmenttherapy(ACT)isanewerpsychotherapythathasgeneratedmuch
clinical and research interest in recent years. However, the approachhasbeguntoreceivestrong
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), gagedinexperiential avoidance, the person attempts to avoid
whichwasdevelopedtoprovideanupdatedbehavioranalytic 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
changeorpersist 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- ACTrepresents 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- AN ANALYSIS OF HOFMANN AND ASMUNDSONS REBUT-
cacious for a variety of clinical conditions based on prelim- TAL TO HAYES ET AL.S CRITIQUE OF CBT
inary trials. (3) Many of the specific components of ACT
showinitial evidence of efficacy in experimental studies. (4)
ACTappearstoworkatleastpartlythroughitshypothesized 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-
TheACTstudiesconductedtodatelendsupportformany 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- Hayes et al. (1999) argue that CBT -based approaches hold
essary to confirm these initial promising findings. However, certain underlying “mechanistic” philosophical assumptions,
the evidence to date appears moderately strong in support of suchthattheypromotethenotion(sometimesimplicitly)that
ACTatthis stage of investigation. Recent meta- analyses of internal mental states are directly causal in relation to behav-
ACToutcomesconductedinawide-rangeofclinicalpopula- ior. In contrast, Hayes et al. (2006) state that ACT is based
tions indicate medium to large effect size differences versus on a pragmatic philosophy called functional contextualism,
comparison conditions (Hayes et al., 2006; Öst, 2008; Pow- which“viewspsychological events as ongoing actions of the
ers, Zum Vörde Sive Vörding, & Emmelkamp, 2009), which whole organism interacting in and with historically and situ-
is consistent with the broader CBT literature. Contrary to ationally defined contexts” (p. 4). Hayes et al. (1999) further
someauthors’claimstothecontraryregardingACT’sempir- explain:
ical status (see Öst, 2008), the American Psychological As-
sociation’s Division 12 (Clinical Psychology) recently inclu Sometypes of cognitive-behavioral therapy, for
ded ACT for depression on its list of empirically-supported example, are based on a computer metaphor (as
treatments, concluding that it has “moderately strong” em- is much of cognitive psychology itself). Like
pirical support based on published clinical trials1.
The increasing popularity of ACT in recent years has be- a computer, humans are thought to store, ac-
guntodrawtheattentionandscrutinyofproponentsoftradi- cess, and process information. In this view, the
tional cognitive- behavioral therapy (CBT), many of whom task when dealing with an unworkable thought
have expressed skepticism about the approach. In recent ar- is to change the form of the thought, just as a
ticles and book chapters, some critics have argued that ACT computermaybechangedbyreplacingmemory
offers relatively minor variations compared with traditional chips or by changing software. This “out with
CBT that may not warrant the widespread clinical and re- the bad, in with the good” mechanistic approach
search attention that the treatment has been receiving (Corri- is quite different from a contextual perspective
gan, 2001; Hofmann, 2008a; Hofmann&Asmundson,2008; whereintheemphasismaybeon“seeingthebad
Leahy, 2008; Öst, 2008; Velten, 2007). The purpose of the thought as a thought, no more, no less.” (p. 21)
current article is to explore emerging criticisms of ACT’s ra- Hofmann and Asmundson (2008) respond that the com-
tionale and treatment model from the traditional CBT com- puter metaphor of CBT is simply “inaccurate” (p. 7). These
munity. The goal is not to “defend” ACT per se, but instead authors further argue that CBT is not mechanistic and is not
to compare and contrast the comments of critics with the concerned with replacing “bad” with “good” thoughts, but
claims of ACT proponents to determine whether these argu- instead is focused on systematically training the individual
ments are logically consistent and empirically justified. Re- to produce more realistic and adaptive evaluations though
cently, Hofmann and Asmundson (2008) published a com-
parison of ACT versus CBT and concluded that ACT may 1 http://www.psychology.sunysb.edu/eklonsky-
be more “old hat” than “new wave.” Specifically, these au- /division12/treatments/depression_acceptance.html
EVALUATINGACCEPTANCEANDCOMMITMENTTHERAPY 57
the modification of underlying information processing bi- 1999). Ultimately, these more basic information processing
ases. HofmannandAsmundsonacknowledgethatCBTaims components are thought to require modification to produce
to correct unrealistic cognitions that produce emotional dis- consistently realistic and adaptive appraisals.
tress, but they further clarify that “if there is good reason to As previously discussed, ACT is based on a contextual
be sad, angry, fearful, worried, and so forth, the CBT thera- philosophy that views the whole organism in its historical
pist will not attempt to change these adaptive responses” (p. and situational context as the level of analysis. In contrast,
7). many forms of CBT assume that putatively faulty “parts”
First, is it true as Hofmann and Asmundson (2008) as- (e.g., distorted automatic thoughts, dysfunctional beliefs, or
sert that the computer metaphor of CBT used by Hayes et al. schemas) of a larger “system” (i.e., the person’s mind) can
(1999) is incorrect? The following is an example of how one be effectively isolated and directly modified to produce be-
cognitive therapy researcher proposed explaining the cogni- havior change. Hofmann and Asmundson (2008) emphasize
tive processes targeted by CBT: that CBT is truly interested in changing bas ic information
Each ICS [Interacting Cognitive Subsystem] processes that are viewed as faulty, such as general infor-
subsystem has a memory that stores copies of mation processing biases and schemas (“I’m an incompetent
all the patterns of information that it takes as in- person”), not simply changing specific distorted cognitions
put. It follows that, where the depressive inter- (“I’m stupid for not being able to understand this new as-
lock configuration has been operating for some signment my boss gave me”). However, this may well be a
time, the recent sections of the Implicational distinction without a difference from the perspective of ACT.
subsystem’s memory store will contain many Cognitive constructs such as schemas are in essence, simply
representations of depression-related schematic larger “parts” of the “whole” that CBT considers to be faulty
models. Once the distraction task is complete, or maladaptive in partic ular ways. In contrast, Hayes et al.
these models will be easily accessed, effectively (1999) explain:
“leaking back” into the data stream circulating Rather than trying to change the form of private
round the central engine, and so restarting the experience, ACT therapists attempt to change
depression interlock configuration. (Teasdale, the functions of private experiences by manip-
1996, p. 39) ulating the context in which some forms of ac-
Such writings clearly use computer-related terminology tivity (e.g., thoughts and feelings) are usually re-
and concepts, which in turn suggest that there are indeed lated to other forms (e.g. overt behaviors).” (p.
mechanistic assumptions in at least “some types” of CBT, 24)
as Hayes et al. claim. To be fair, Hayes et al. could also
have noted that there have been attempts to understand CBT In ACT, there is no assumption that a person’s thoughts,
from less mechanistic perspectives, such as Psychological beliefs, rules, conditional statements, schemas, attributions,
Constructivism (Mahoney, 1991). appraisals, evaluations, or any private events per se require
Hofmann and Asmundson (2008) are on firmer ground, direct modification efforts by the therapist in order for the
though, when they argue that CBT therapists are concerned patient to achieve his/her desired behavioral changes. Put an-
withmorethansimplyreplacing“bad”thoughtswith“good” other way: all of these cognitive constructions would be con-
ones. It is true that descriptions of CBT often focus on sidered “forms” of private experience from an ACT stand-
changing specific negative thoughts offered by the patient. point.
HofmannandAsmundson,however,clarifythattheultimate Furthermore, Hayes et al. (1999) note that mechanistic
aimofCBTistochangeinformationprocessingbiasesmore approaches assume an ontological realism such that: “We
broadlysothatevaluationsbetterconformtotherealityofthe can know what is because what is is real” (emphasis added,
situation or are more adaptive in nature. At least in their early p. 20). However, ACT considers itself “a-ontological” in
writings, Hayes et al. (1999) admittedly present an oversim- the sense that it assumes that “what is true is what works”
plifieddescription of CBTwhentheyimplythatitstherapists (p. 20). In other words, CBT’s focus on identifying and
only focus on good-bad thought swapping techniques. changing putatively distorted or faulty information process-
Evenifweacceptthesepointsofclarification,Hayesetal. ing biases necessarily implies a certain degree of realism and
(1999) would likely still view CBT as implicitly mechanistic mechanism. OnecanlegitimatelyarguethatCBTmaynotbe
from an epistemological standpoint. For example, the Beck- as extreme or classic in its mechanism or realism as Hayes
ian CBTtherapist encourages the patient to examine particu- et al. seem to imply. However, Hofmann and Asmundson’s
lar “automatic thoughts” associated with an emotionally dis- (2008)responsefailstofullyaddresstheimplicitmechanistic
tressing situation, and then helps him/her to identify and cor- assumptions in traditional CBT as highlighted by Hayes and
rect the “distortions” (e.g., black-or-white or dichotomous colleagues. Of course, it remains an open empirical question
thinking) contained in these cognitions. These distorted au- whether a mechanistic versus contextual approach is actu-
tomatic thoughts are believed to stem from more general un- ally moreusefulfromapsychotherapeuticorscientificstand-
derlying dysfunctional beliefs or rules, and even more basic point.
“core beliefs” or schemas that are largely derived from child-
hood experie nces (Beck, 2008; Beck, 1995; Needleman,
58 GAUDIANO
Critique 2: CBT Is “Symptom” Focused A. T. Beck et al. describe the use of symptom allevia-
Hayes (2004a) also argues that CBT is more narrowly fo- tiontechniquesinCBT,includingteachingpatients“avariety
cusedontargetingidentified“symptoms”orwhathecallsthe of self-management procedures to control their anxiety” (p.
formsandfrequenciesofbehavior(i.e.,“first-order”change). 181). These authors further explain that such techniques are
In contrast, he asserts that ACT is more broadly focused on deemed effective because depression can be understood as
altering the functions and contexts of behavior (i.e., “second- being comprised of various interacting systems (e.g., affec-
order” change). For example, Hayes writes: tive, cognitive, behavioral, and physiological), and thus tar-
geting one domain will produce changes in the others (again,
[T]he new behavior therapies carry forward the notice the implicitly mechanistic philosophy of such an ar-
behavior therapy tradition, but they (1) aban- gument). Hofmann and Asmundson are correct in pointing
don a sole commitment to first-order change, out that the primary focus of CBT is to change cognitive bi-
(2) adopt more contextualistic assumptions, (3) ases because they are assumed to be the fundamental dys-
adopt more experiential and indirect change functional processes producing distress. Thus, Hofmann and
strategies in addition to direct strategies, and Asmundson do not see these processes as “symptoms” per
(4) considerably broaden the focus of change. se. However, this goal is accomplished through a variety
(Hayes, 2004a, p. 6) of different strategies, and direct symptom alleviation is an
important part of that process from both practical and theo-
Hofmann and Asmundson (2008) disagree with Hayes’ retical levels. Most CBT therapists and patients very much
premise that CBT is focused on symptom reduction: appreciate this aspect of the therapy and do not see it as a
weakness at all.
The goal in CBT is to reduce or eliminate But how does one define a symptom? It appears that the
psychological distress. This goal incorporates crux of the disagreement between Hofmann and Asmundson
symptomreduction. The process to achieve this (2008) and Hayes (2004a) actually comes from their differ-
goal, however,isnotthroughdirectionmodifica- ingconceptualizationsofwhatthe“symptom”isversuswhat
tion of the symptoms but, instead, through iden- the mechanism is that produces the “symptom.” Understand-
tifying and modifying dysfunctional cognitions ably, Hofmann and Asmundson view dysfunctional cogni-
that are causally related to symptom interpreta- tions as direct causal agents that affect behavior. However,
tion and related psychological distress. (p. 7) Hayes and colleagues reject this premise first and foremost
from philosophical grounds. Hayes et al. (1999) explain:
In other words, Hofmann and Asmundson argue that the “From a functional contextualistic perspective, only events
aim of CBT is to reduce the emotional distress related to external to behavior can cause’ behavior” (p. 55, also see
symptoms,notthroughthedirectreduction of symptoms per Hayes & Brownstein, 1986). Thus, a cognition, which is
se, but instead by altering the “cognitive distortion and mis- considered a type of “private” or internal event, cannot liter-
interpretation that underlies the emotional distress associated ally determine behavior from this perspective. This premise
with these [symptoms]” (p. 8). is, of course, subject to debate and stems from ACT’s roots
First, manycognitivetherapistswouldlikelydisagreewith in radical behaviorism. But from an ACT perspective, strate-
Hofmann and Asmundson’s (2008) premise that the goal of gies to alter cognitive processes directly would be viewed
CBTisnottoreducedistress through the direct modification as attempts to change a symptom or what is more broadly
of symptoms, but only though the alteration of underlying considered a “first-order” problem, not the factors actually
cognitive processes. Other authors who have research back- producingtheproblem. Aspreviouslydiscussed, ACToffers
grounds and training in CBT as well as ACT also view this its own theory for how psychopathology is created and main-
as a distinction between the two approaches (Forman & Her- tained based on RFT (Hayes et al., 2001). Again, Hofmann
bert, 2009). Hofmann and Asmundson fail to provide cita- and Asmundson appear to misunderstand the more funda-
tions or direct quotations from any primary CBT sources to mental aspects of Hayes et al.’s premise, and thus their re-
support this particular radical interpretation of CBT. Thus, it sponseultimately falls short in addressing the root of the dis-
is difficult to precisely determine the origins of these claims. agreement between CBT and ACT.
Other prominent CBT theorists, however, seem to contra-
dict Hofmann and Asmundson’s assessment. For example, Critique 3: CBT Is Weakly Linked to Basic Cognitive Science
in their seminal book Cognitive Therapy of Depression,A.
T. Beck, Rush, Shaw, and Emery (1979) explain: Hayes et al. (2006) also argue: “The link between cognitive
therapy and basic cognitive science continue to be weak” (p.
Since the selection of a focal point takes into ac- 3). In contrast, Hayes and colle agues point to ACT’s link to
count not only what the patient perceives as his learning theory and their basic research program called RFT.
crucial realistic problems but also the feasibility Hofmann and Asmundson (2008) contest this conclusion:
of resolving these problems promptly, there are “We are surprised that this critique was raised, perhaps be-
times when consideration of the patient’s more cause wehavebeendirectlyinvolvedinanumberofexciting
general problems has to be postponed until his studies that directly link CBT and other scientific fields, most
dis abling symptoms can be alleviated. (p. 167) notably clinical neuroscience” (p. 8). These authors pro-
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