A brief overview of Acceptance and Commitment Therapy

Dr. Joseph Ciarrochi, School of Psychology, University of Wollongong

ACT targets six core processes that are designed to build psychological flexibility.
Psychologocial flexibility refers to an individuals ability to connect with the present moment
fully, as a conscious human being, and to change or persist in behavior that is in line with
their identified values (Hayes, et al., 1999).
Increasing psychological flexibility involves helping clients to disentangle
themselves from the cycle of experiential avoidance and cognitive fusion, not by challenging
or changing their thoughts and emotions for example, but by learning to react more mindfully
to such experiences, so that they no longer seem to be barriers (Ciarrochi, et al., 2006).
Clients are encouraged to shift their energies away from experiential control and towards
valued activity, and to consistently choose to act effectively, even in the presence of difficult
private events. For a detailed and comprehensive account of ACT readers are referred to
Hayes et al. (Hayes, et al., 1999).
The ACT treatment model consists of six sub-processes that are organized into a
hexaflex (see Figure 1). The hexaflex can be divided into two main components. The first
includes acceptance and mindfulness processes (acceptance, defusion, the present moment,
and a transcendent sense of self), and the second reflects commitment and behavioural
change processes (values, committed action, the present moment and a transcendent sense of
self). The ACT practitioner targets these six processes in order to build psychological
flexibility.

Figure 1: The six core processes targeted by ACT are expected to build psychological
flexibility
The hexaflex illustrates that these processes are all connected and support each other.
There is no correct order for focusing on the processes and not all individuals need to
concentrate extensively on each of the processes (Strosahl, et al., 2004; Hayes, et al., 2005).
The ultimate goal is to help people to persist in or change their behavior, depending on what
the situation affords, in order to move towards what they value.
ACT clinicians use a number of exercises for each process to enhance adoption and
understanding of relevant skills (for more detail see Hayes, et al., 1999; Strosahl, et al.,
2004). These include metaphor, paradox and experiential exercises that aim to undermine the

power of experiential avoidance and cognitive fusion. A brief description of each process will
now be provided.
Acceptance. The focus of this ACT process is to develop and enhance an individuals
willingness to have and accept their private experiences. Treatment involves exploring the
futility of emotional control and avoidance, which can often paradoxically increase an
individuals level of distress and deter them from engaging in purposeful and vital, value
driven behaviour. Instead, individuals are encouraged to accept their private experiences,
when doing so helps them engage in valued behavior.
Defusion is a process that involves weakening the language processes that promote
fusion (Hayes, et al., 1999; Strosahl, et al., 2004). People learn to see thoughts for what they
are and not what they say they are (Hayes, et al., 1999), for example, symbols of ones
experience and not actual descriptive realities. Defusion exercises help people to notice
their language processes as they unfold and to watch the thoughts come and go, almost like a
neutral observer. Defusion thus involves a radical shift in context, where thoughts are
observed events, rather than literal truths that must dictate behavior.
Getting in contact with the present moment. This ACT process is often equated to
mindfulness. Clients are taught to build their awareness of their private experiences and be
fully open to what is happening in the present moment. In the mindful state, thoughts are
expected to be experienced as what they are, events that come and go, rather than what they
often seem to be, truths that bind or actual barriers. For example, a self-critical thought such
as I am useless can be viewed as a passing event rather than something that must control
behavior. Mindfulness also connects to the values and commitment component of ACT, in
that it allows the regulation of action that is informed by needs, feelings, values, and their fit
with the current situation (Brown, et al., 2007). According to Strosahl et al. (2004) and Hayes

et al. (1999), the qualities that reflect this process are vitality, spontaneity, connection, and
creativity.
Self-as-context. Clients are taught to build their awareness of their observing self, or
self-as-context, and work on letting go of their attachment to a conceptualised self (i.e. I am
boring; I am useless). The self-as-context is independent of content: It is the place where
content is observed. No matter how many self-statements we generate about who we are (I
am a father: I am an athlete; I am not good enough), there is an I that can observe these
self-statements. This I is experienced as constant and stable, whilst the self-evaluations
come and go (Hayes, et al., 1999). From the perspective of self-as-context, people come to
realize that they can let go of unhelpful self-evaluations and retain a sense of self (Pierson, et
al., 2004).
Values. Values refer to the directions in life that individuals choose which guide their
behaviour. Thus, values are never really achieved or obtained, yet they are always present
every time an individual chooses them (Hayes, et al., 1999; Pierson, et al., 2004). Individuals
who are entangled in fusion and experiential avoidance are more likely to engage in
behaviours that are inconsistent with their values. For example, even though an individual
may value a relationship, they may engage in destructive social behavior, because they are
afraid of intimacy. People in ACT learn to choose willingness to experience difficult thoughts
and feelings, in order to engage in valued behaviour (Strosahl, et al., 2004).
Committed Action. Engaging in value-directed behaviour can often produce difficult
experiences such as distress, failure, and fusion. ACT helps people to see that choosing a
valued direction is not a permanent thing. The choice must be made again and again, for
example, after failure. ACT helps prepare people for the difficult feelings and thoughts that

will show up due to their valued striving and to be more willing to carry those feelings and
thoughts in order to do what it takes to move in a valued direction.
The inflexahex is another way of looking at the various processes in ACT (Bach,
Moran, & Hayes, (2008). Each positive process in ACT has a negative counterpart, as
illustrated in Figure 2.

Figure 2: The inflexahex model of suffering and problematic behavior

Independent evaluations of empirical support for ACT

The American Psychological Association suggests ACT has research support for chronic pain
(http://www.div12.org/PsychologicalTreatments/treatments/chronicpain_act.html) and
depression
(http://www.div12.org/PsychologicalTreatments/treatments/depression_acceptance.html).

The United States Substance Abuse and Mental Health Services Administration (SAMHSA)
has now listed ACT as an empirically supported method as part of its National Registry of
Evidence-based Programs and Practices (NREPP). It is now available on the NREPP Web
site at http://174.140.153.167/ViewIntervention.aspx?id=191.

A sample of theoretical and review articles relevant to ACT

(collated by Steve Hayes)

Longmore, R. J., & Worrell, M. (2007). Do we need to challenge thoughts in

cognitive behavioral therapy? Clinical Psychology Review, 27, 173187.
A comprehensive review of the evidence in three keys areas that
question the idea that trying to change the form of thoughts is
helpful. It finds little evidence that specific cognitive interventions
significantly increase the effectiveness of CBT or that cognitive
change is causal in the symptomatic improvements achieved in CBT.
It does not find enough evidence to conclude that there is an early
rapid response to CBT (before cognitive methods). Overall, the
review supports the view of the basic ACT criticism of traditional
CBT.
Williams, J. C. & Lynn, S. J. (2010). Acceptance: An historical and
conceptual review. Imagination, cognition, and personality, 30, 5-56.
Good historical review of the acceptance concept.
Hayes, S. C., Luoma, J., Bond, F., Masuda, A., and Lillis, J. (2006). Acceptance and
Commitment Therapy: Model, processes, and outcomes. Behaviour Research and
Therapy, 44, 1-25.
[A meta-analysis of ACT processes and outcomes. Reviews all AAQ and ACT clinical
studies]
Ruiz, F. J. (2010). A review of Acceptance and Commitment Therapy (ACT) empirical
evidence: Correlational, experimental psychopathology, component and outcome
studies. International Journal of Psychology and Psychological Therapy, 10, 125-162.
[A meta-analysis of ACT processes and outcomes].

Hayes, S. C., Masuda, A., Bissett, R., Luoma, J. & Guerrero, L. F. (2004).
DBT, FAP, and ACT: How empirically oriented are the new behavior
therapy technologies? Behavior Therapy, 35, 35-54. [Tutorial review
of the empirical evidence on ACT, DBT, and FAP]
Hayes, S. C. (2004). Acceptance and Commitment Therapy, Relational
Frame Theory, and the third wave of behavioral and cognitive
therapies. Behavior Therapy, 35, 639-665. [Makes the case that ACT
is part of a larger shift in the field.]
Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K.
(1996). Emotional avoidance and behavioral disorders: A functional
dimensional approach to diagnosis and treatment. Journal of
Consulting and Clinical Psychology, 64, 1152-1168. [This reviews the
data relevant to an ACT approach to psychopathology, as of the
mid-90s. Still relevant]
Salters-Pedneault, K., Tull, M. T., & Roemer, L. (2004). The role of
avoidance of emotional material in the anxiety disorders. Applied
and Preventive Psychology, 11, 95-114. [A more recent review of
much of the experiential avoidance literature]

Evidence that ACT works by increasing psychological flexibility

(Last Updated May 5, 2009)
This review focuses primarily on why ACT works, i.e., the mechanisms by which
ACT improves client well-being and behavior. It should be clear from this review that ACT
appears to be effective for a wide variety of client issues, and it seems to work by improving
markers of psychological flexibility.
ACT interventions fall into two broad categories: Nonclinical and behavioural
medicine and mental health and substance abuse. An overview of these studies are presented
in Table 1 and 2, respectively. Not every ACT-related outcome study is described in these
tables. Given our focus on detecting reliable meditational effects, we did not describe small
sample pilot studies (n < 6; e.g., (Twohig, et al., 2007) ) and ACT efficacy interventions that
were not designed to assess meditational hypotheses (e.g., (Wicksell, et al., 2009).

Concerning nonclinical and behavioural medicine interventions (Table 1), there was
substantial breadth in the target populations, which included people who have a child with
autism, work in organizational settings, work as counsellors, have chronic pain and other
health problems, have cancer, and have a history of smoking. Concerning outcomes, ACT
has been shown to improve mental health and well-being and promote a broad range of
value-consistent or positive behaviors, such as increased innovativeness, reduced taking of
sick days and utilization of medical resources, reduced cigarette smoking, improved diabetes
self-care, positive, non-prejudiced actions, better weight maintenance, behavioural activity
despite pain, and willingness to use empirically supported treatments.
Turning to the issue of mediation, of the studies that used the general Acceptance and
Action Questionnaire ( AAQ) as a measure of psychological flexibility, there were three
studies in which ACT improved AAQ (Bond, et al., 2000; Flaxman, 2006; Varra, et al.,
2008), and two studies that did not reliably improve the AAQ (Blackledge, et al., 2006;
Bilich, et al., 2009) . Blackledge and Hayes (2006) found no AAQ improvements from pre to
post (p > .50; one week after intervention) , and a marginal effect from pre to follow-up (p = .
043, one-tailed). Bilich and Ciarrochi (2009) found no improvements from pre to post. Both
of these studies engaged in extensive adherence ratings which indicated considerable
presence of all ACT-consistent processes (Figure 1) during the intervention. Two clinical
studies also failed to find that ACT improved general AAQ (to be discussed soon)
In contrast to studies that used the general AAQ, all eight studies that focused on
population specific measures of acceptance found effects. ACT improved acceptance and
flexibility related to smoking (Gifford, et al., 2004), diabetes (Gregg, et al., 2007), prejudice
(Lillis, et al., 2007), weight (Lillis, et al., 2009), epilepsy (Lundgren, et al., 2008), and
chronic pain (McCracken, et al., 2005; Vowles, et al., 2008; Wicksell, et al., 2008). In

addition, there was evidence that ACT influenced population-specific believability measures
(Hayes, et al., 2004a; Varra, et al., 2008).

Table 1: ACT intervention studies that assess mediators of change: Nonclinical and behavioural medicine
Authors

Intervention design and sample size (in parentheses)

Mediation findings

Bilich and
Ciarrochi
(2009)
Blackledge,
& Hayes,
(2006)
Bond, &
Bunce,
(2000)

ACT (79) vs WL (45) targeting general mental health and

valued living amongst the police force

ACT (24) vs. innovation promotion program (IPP; 21) vs. WL

(20) for participants in a media organisation

AAQ mediated changes in general mental health and innovativeness only in the ACT
condition. Attempts at modifying stressors mediated the outcomes (depression and
innovativeness) in the IPP condition

Branstetter et
al.,(2004)

ACT (25) vs. CBT (22) for end stage cancer patients

Dahl, et a.
(2004)

ACT + Medical Treatment-As-Usual (MTAU) (11) vs. MTAU

(8) for public health service employees with chronic stress/pain

Flaxman
(2006)

ACT(47) vs. stress inoculation training (SIT; 56) vs. weight list
control (51) for government employees

Avoidant coping (mental disengagement) mediated the effect of ACT on participants level
of reduced distress and improved quality of life during treatment. Participants in the ACT
condition showed significantly less anxiety and distress than participants in the CBT
condition.
ACT participants used fewer sick days and fewer treatment resources than those in MTAU.
No differences were found in levels of pain, stress, or quality of life, suggesting that ACT
worked by helping clients to act effectively and flexibly in the presence of symptoms.
The positive impact of ACT on mental health was mediated by an increase in AAQ. The
impact of SIT was partially mediated by a decrease in dysfunctional attitudes

Gifford et al.
(2004)

ACT (38) vs. Nicotine Replacement Treatment (NRT) (38) for

adults with a smoking history

Participants in the ACT condition had better long-term smoking outcomes at 1-year follow-up
than those in NRT. Mediational analyses indicated that the ACT outcomes at 1 year were
mediated by improvements on the Avoidance and Inflexibility Scale (avoidance strategies
related to smoking and smoking cessation). Mediator change occurred prior to outcome
change.

Gregg, et al.,
(2007)

ACT + education (43) vs. Education workshop (38) for adults

with Type 2 diabetes

AAQ (diabetes focus) mediated the beneficial influence of ACT on diabetes self-care (as
indicated in self-reports and biological measures)

Hayes,
Bissett, et
al., (2004a)

ACT (30) vs. Multicultural Training (MT, 34) vs. Educational

control (29) for substance abuse counsellors attitudes and
burnout

ACT and MT reduced stigmatizing attitudes, and ACT showed greater reductions in burnout
than MT. ACT, but not MT, effects were mediated by reductions in the believability of
negative thoughts towards clients

ACT (20) for parents / guardians of children diagnosed with

autism

ACT group had significant improvements in general mental health, and were significantly
more successful at living their family-related values. There was no effect of intervention on
AAQ.
Marginal effect of intervention on AAQ. Evidence that believability of dysfunctional thoughts
mediated the relationship between intervention and outcomes such as depression.

Hesser, et al.
(2009)

ACT (19) for clients with tinnitus distress

Participants level of in-session acceptance and cognitive defusion behaviors mediated the
impact of positive treatment effects of ACT on tinnitus distress. An acceptance and defusion
process measure predicted future symptom improvements

Lillis &
Hayes.
(2007)

ACT vs educational lecture for prejudice, presented to

participants (32) in counterbalanced order

Only the ACT intervention was effective at increasing positive behavioral intentions at post
and 1-week follow up, and these effects were partially mediated by acceptance of prejudicial
thoughts and recognition that these thoughts do not act as barriers to non-prejudicial action

Lillis et al.,
(2009)

ACT (40) vs. weight list control (44) for adults who had
completed at least 6 months of any structured weight loss
program in the past 2 years. The intervention targeted obesityrelated stigma and distress.

ACT participants showed greater improvements in obesity-related stigma, quality of life,

psychological distress, and weight. Improvements in a weight specific AAQ mediated
changes in outcome

Lundgren, et
al.(2006;
2008)

ACT (14) or supportive treatment (ST, 13) for institutionalized

South Africans with epilepsy

ACT had significant beneficial effects on seizures, quality of life, and well-being compared
with ST. The beneficial effects of ACT were mediated by epilepsy-related acceptance, values
attainment,, and persistence

McCracken,
et al., (2005)

ACT (108) for patients with chronic pain

ACT improved emotional, social, physical functioning, and reduced healthcare visits for pain.
ACT significantly increased acceptance of pain and willingness to engage in activities in the
presence of pain (CPAQ), and this increase was associated with decreases in depression,
anxiety, physical and psychosocial disability, and sit-to-stand performance.

Varra, et al.,
(2008)

ACT (30) + empirically supported treatment (EST) workshop

vs. education & EST (30) for drug counsellors attitudes toward
EST

AAQ and a reduction in the believability of barriers mediated the impact of the ACT
intervention on counselors willingness to use ESTs.

Vowles, &
McCracken
(2008)

ACT (177) for chronic pain patients who had completed an

interdisciplinary treatment program

Wicksell, et
al. (2008)

ACT-based Intervention (ABI; 11) vs. treatment as usual (11)

for patients with chronic pain and whiplash associated
disorders

ACT reduced pain, depression, pain-related anxiety, disability, medical visits, and physical
performance. ACT increased acceptance of pain and willingness to engage in activities in the
presence of pain (CPAQ), and increases in these processes were associated with
improvements in outcomes.
ABI was better than control in improving life satisfaction, and reducing pain disability, fear of
movements, and depression. ABI also improved psychological inflexibility (pain specific
measure). No explicit meditational analysis conducted.

Note: AAQ = Acceptance and Action questionnaire, a measure of psychological flexibility

We turn our review now to a consideration of ACT interventions for mental health and
substance abuse (Table 3). ACT has shown some efficacy in treating a wide variety of
disorders, including psychosis, social anxiety, anxiety and depression, borderline personality
disorder, obsessive compulsive disorder, substance abuse, and tinnitus distress.

Concerning the impact of ACT on the general AAQ, there were two failures of ACT
to influence the AAQ (Block, 2002; Hayes, et al., 2004b; Hayes, et al., 2006), and 10
successes (Zettle, 2003; Gratz, et al., 2006; Woods, et al., 2006; Dalrymple, et al., 2007;
Forman, 2007; Lappalainen, et al., 2007; Luoma, et al., 2008; Roemer, et al., 2008; Twohig,
2009; Kocovski, et al., In press). ACT has also been shown to reduce believability of
hallucinations (Bach, et al., 2002; Guadiano, et al., 2006) and dysfunctional thoughts (Zettle,
et al., 1986; Zettle, et al., 2009).
Similar to the studies involving normal populations and behavioural medicine, the
clinical studies generally showed changes in the mediator occurring at the same time as
changes in the outcome (the two time point model). However, four studies did provide
evidence for the three time-point model. . Hesser et al. (2009) reliably coded the extent that
in-session behaviors reflected either acceptance or cognitive defusion. They found that the
peak level and frequency of cognitive defusion behaviors and peak level of acceptance rated
in session 2 predicted symptom reduction six months following treatment. They showed that
these relationships could not be accounted for by improvements that had occurred prior to the
measurement of defusion and acceptance. Similarly, Dalrymple & Herbert (2007) and
Kocovski et al. (In press) showed that earlier changes in the AAQ predicted later changes in
symptom severity, even after controlling for earlier changes in symptoms.

In another study, Twohig et al. (2009) collected session data on believability of

obsessions and willingness to have obsessions without reacting to them. Time lag
correlations suggested that the ACT processes were more likely to predict obsessive
symptoms than vice versa. This study along with the other three suggest that acceptance and
defusion are likely to be precursors of outcomes, rather than merely concomitants or
consequences

Table 2: ACT intervention studies that assess mediators of change: Mental health and substance abuse
Study

Intervention design and sample size (in parentheses)

Mediation findings

Bach &
Hayes (2002)

TAU (40) vs. ACT + TAU (40) for treatment of positive

psychotic symptoms

Changes in believability of hallucinations mediated the effect of the ACT intervention on

rehospitalisation of clients.

Block (2002)

ACT (13), cognitive-behavioral group therapy (CBGT;13 ), and

a wait list control (13) in the treatment of social phobia

Both ACT and CGBT participants showed reductions in anxiety. ACT participants showed less
behavioural avoidance to a social situation than CBGT participants. Neither ACT nor CBGT
had a significant effect on AAQ

Dalrymple &
Herbert
(2007)

ACT (19) for adults with social anxiety disorder

Earlier improvements on AAQ mediated later reduction in participants level of distress and
increase in quality of life. ACT incongruent process measure (skill at controlling private
experience) did not mediate change

Forman et.
al., (2007)

ACT (55) vs. CT (44) for university students with anxiety and/or
depression

CT and ACT shown to be effective in reducing symptom such as depression and anxiety.
Changes in AAQ, and acceptance and acting with awareness component of mindfulness more
strongly associated with outcome in ACT relative to CBT group. Changes in observing and
describing components of mindfulness more strongly associated with outcomes in CT
condition.

Gaudiano, &
Herbert,
(2006)

ACT + enhanced treatment as usual (ETAU; 19) vs. ETAU (21)

for hospitalized patients experiencing psychotic symptoms

ACT had more beneficial effects at short term follow-up for social impairment and distress.
ACT alone decreased believability of hallucinations and reductions in believability were
associated with reductions in distress

Gratz &
Gunderson
(2006)

ACT and DBT influenced intervention + TAU (12) vs.

Individual outpatient therapy (TAU waitlist) (10) for females
with BPD

The intervention had positive effects on self-harm, emotion dysregulation, BPD-specific

symptoms, and distress, and improved scores on the AAQ. No formal test of mediation.

Hayes,
Wilson, et al.

ACT (42) vs. Intensive Twelve-Step Facilitation (ITSF) (44) vs.

Methadone maintenance only (38) for adults using methadone /

ACT and ITSF reduced objectively assessed drug use. ACT failed to change the AAQ (Hayes,
et al., (2006)

(2004b)

opiates

Kocovski, et
al. (In press)

ACT-informed Mindfulness and Acceptance group therapy (42)

for social anxiety disorder

AAQ from baseline to mid-treatment significantly predicted change in social anxiety from
mid-treatment to post-treatment, controlling for change in anxiety from baseline to midtreatment. There was not evidence of the change in AAQ occurring prior to the change in
social anxiety symptoms.

Lappalainen,
R. et al.
(2007)

Outpatients (28) randomly assigned to CBT or ACT conducted

by14 trainee therapists.

Clients treated with ACT showed better symptom improvement than CBT. ACT improved
AAQ but not self-confidence, whereas CBT improved self-confidence but not AAQ.
Improvement in acceptance and self-confidence were correlated with improvements in
symptoms. When these variables were covaried, acceptance was the unique predictor.

Luoma, et al.,
(2008)

ACT (88) for treatment of self-stigma in substance abusing

population

ACT improved AAQ, and changes in AAQ were strongly correlated with changes in
internalized shame. No formal mediation test.

Roemer, et
al.,(2008)

ACT influenced acceptance-based behaviour therapy (ABBT)

(15) vs. Waiting list control (16) for adults with GAD

ABBT significantly reduced GAD-specific symptoms and depression, reduced avoidance

(AAQ), and increased mindfulness.

Twohig,
(2009)

ACT (17) versus Progressive relaxation training (PRT; 17) for

obsessive compulsive disorder

Woods, et al.,
(2006)

ACT / Habit Reversal Training (ACT/HRT) (12) vs Waitlist

control (13) for adults with trichotillomania (TM)

ACT produced significantly greater decreases in OCD severity and AAQ than PRT. AAQ was
shown to partially mediate outcomes. Analysis of weekly session data suggested that changes
in ACT processes proceeded and predicted changes in OCD severity.
ACT was better that WL in reducing hair pulling severity, hairs pulled, anxiety, and
depression. Decreases on AAQ were correlated with reductions in TM symptoms

Zettle, R. D.
(2003)

ACT (12) vs. Systematic desensitization (SD; 12) for college

students experiencing math anxiety

ACT and SD reduce math and test anxiety, and experiential avoidance (AAQ). SD alone
reduced trait anxiety. Reductions in experiential avoidance associated with reductions in
anxiety only in ACT group.

Zettle. &
Hayes,
(1986)

Comprehensive distancing (early form of ACT; 9) vs. Cognitive

restructuring (9) for depression

Comprehensive distancing (CD) more effective than CT on depression outcomes and in

reducing the believability of dysfunctional thoughts, but not the frequency of those thoughts.
Reductions in believability came before improvements in depression

Zettle &
Rains (1989;
2009)

ACT (13) vs CT (12) for depressed female adults

ACT produced greater reductions in depression than CT, and the differences between ACT and
CBT were mediated by reductions in the believability of dysfunctional thoughts.

*Note: this table excludes ACT efficacy studies that did not measure correlates of psychological flexibility. AAQ = Acceptance and Action
Questionnaire; TAU = treatment as usual; CT = cognitive therapy; CPAQ = Chronic Pain Acceptance Questionnaire.

More recent RCT evidence not cited in the table

Im having trouble keeping up with the rate of publications, and
dont have time to integrate them into the above tables. So I will keep a
list of RCTs (post Powers metaanalysis) here.
RCTs published since the 2009 Powers meta-analysis (or
reanalyses and meditational analyses of RCTs)

Bohlmeijer, E. T., Fledderus, M., Rokx, T. A. J. J., & Pieterse, M. E. (2011). Efficacy
of an early intervention based on acceptance and commitment therapy for adults
with depressive symptomatology: Evaluation in a randomized controlled trial.
Behaviour Research and Therapy, 49(1), 62-67.
Brown, L. A., Forman, E. M., Herbert, J. D., Hoffman, K. L., Yuen, E. K., & Goetter,
E. M. (2011). A randomized controlled trial of acceptance-based behavior therapy
and cognitive therapy for test anxiety: A pilot study. Behavior Modification, 35(1),
31-53.
Flaxman, P. E., & Bond, F. W. (2010). A randomised worksite comparison of
acceptance and commitment therapy and stress inoculation training. Behaviour
Research and Therapy, 48(8), 816-820.
Flaxman, P. E., & Bond, F. W. (2010). Worksite stress management training:
Moderated effects and clinical significance. Journal of Occupational Health
Psychology, 15(4), 347-358.
Fledderus, M., Bohlmeijer, E. T., Smit, F., & Westerhof, G. J. (2010). Mental health
promotion as a new goal in public mental health care: a randomized controlled
trial of an intervention enhancing psychological flexibility. American Journal of
Public Health, 100(12), 2372-2372.
Gaudiano, B. A., Herbert, J. D., & Hayes, S. C. (2010). Is it the symptom or the
relation to it? Investigating potential mediators of change in Acceptance and
Commitment Therapy for psychosis. Behavior Therapy, 41, 543-554.
Gifford , E. V., Kohlenberg, B., Hayes, S. C., Pierson, H., Piasecki, M., Antonuccio,
D., & Palm, K. (in press). Does acceptance and relationship focused behavior
therapy contribute to bupropion outcomes? A randomized controlled trial of FAP
and ACT for smoking cessation. Behavior Therapy.
Hayes, L., Boyd, C. P., & Sewell, J. (2011). Acceptance and Commitment Therapy
for the treatment of adolescent depression: A pilot study in a psychiatric
outpatient setting. Mindfulness.
Hesser, H., Westin, V., Hayes, S. C., & Andersson, G. (2009). Clients in-session

acceptance and cognitive defusion behaviors in acceptance-based treatment of

tinnitus distress. Behaviour Research and Therapy, 47, 523528.
Johnston, M., Foster, M., Shennan, J., Starkey, N. J., & Johnson, A. (2010). The
effectiveness of an acceptance and commitment therapy self-help intervention
for chronic pain. Clinical Journal of Pain, 26(5), 393-402.
Juarascio, A. S., Forman, E. M., & Herbert, J. D. (2010). Acceptance and
commitment therapy versus cognitive therapy for the treatment of comorbid
eating pathology. Behavior Modification, 34(2), 175-190.
Lillis, J., Hayes, S. C., Bunting, K., & Masuda, A. (2009). Teaching acceptance and
mindfulness to improve the lives of the obese: A preliminary test of a theoretical
model. Annals of Behavioral Medicine, 37(1), 58-69.
Lundgren, T., Dahl, J., Yardi, N., & Melin, L. (2008). Acceptance and Commitment
Therapy and yoga for drug-refractory epilepsy: a randomized controlled trial.
Epilepsy & Behavior : E&B, 13(1), 102-108.
Muto, T., Hayes, S. C., & Jeffcoat, T. (in press). The effectiveness of Acceptance
and Commitment Therapy bibliotherapy for enhancing the psychological health
of Japanese college students living abroad. Behavior Therapy.
Pez, M. B., Luciano, C., & Gutirrez, O. (2007).Tratamiento psicolgico para el
afrontamiento del cncer de mama. Estudio comparativo entre estrategias de
aceptacin y de control cognitivo. Psicooncologa, 4, 75-95. [Psychological
treatment for coping with breast cancer. A comparative study of acceptance and
cognitive-control strategies].
Pearson, A. N., Follette, V. M. & Hayes, S. C. (in press). A pilot study of
Acceptance and Commitment Therapy (ACT) as a workshop intervention for body
dissatisfaction and disordered eating attitudes. Cognitive and Behavioral
Practice.
Petersen, C. L., & Zettle, R. D. (2009). Treating inpatients with comorbid
depression and alcohol use disorders: A comparison of acceptance and
commitment therapy versus treatment as usual. The Psychological Record, 59(4),
521-536.
Roemer, L., Orsillo, S. M., & Salters-Pedneault, K. (2008). Efficacy of an
acceptance-based behavior therapy for generalized anxiety disorder: evaluation
in a randomized controlled trial. Journal of Consulting and Clinical Psychology,
76(6), 1083-1089.
Smout, M. F., Longo, M., Harrison, S., Minniti, R., Wickes, W., & White, J. M. (2010).
Psychosocial treatment for methamphetamine use disorders: A preliminary
randomized controlled trial of cognitive behavior therapy and acceptance and

commitment therapy. Substance Abuse, 31(2), 98-107.

Treanor, M., Erisman, S. M., Salters-Pedneault, K., Roemer, L., & Orsillo, S. M.
(2011). Acceptance-based behavioral therapy for GAD: effects on outcomes from
three theoretical models. Depression and Anxiety, 28(2), 127-136.
Twohig, M. P., Hayes, S. C., Plumb, J. C., Pruitt, L. D., Collins, A. B., HazlettStevens, H., et al. (2010). A randomized clinical trial of acceptance and
commitment therapy versus progressive relaxation training for obsessivecompulsive disorder. Journal of Consulting and Clinical Psychology, 78(5), 705716.
Varra, A. A., Hayes, S. C., Roget, N., & Fisher, G. (2008). A randomized control
trial examining the effect of acceptance and commitment training on clinician
willingness to use evidence-based pharmacotherapy. Journal of Consulting and
Clinical Psychology, 76(3), 449-458.
Wicksell, R. K., Melin, L., Lekander, M., & Olsson, G. L. (2009). Evaluating the
effectiveness of exposure and acceptance strategies to improve functioning and
quality of life in longstanding pediatric pain--a randomized controlled trial. Pain,
141(3), 248-257.
Wicksell, R. K., Ahlqvist, J., Bring, A., Melin, L., & Olsson, G. L. (2008). Can
exposure and acceptance strategies improve functioning and life satisfaction in
people with chronic pain and whiplash-associated disorders (WAD)? A
randomized controlled trial. Cognitive Behaviour Therapy, 37(3), 1-14.
Wicksell, R. K., Olsson, G. L., & Hayes, S. C. (2010). Psychological flexibility as a
mediator of improvement in patients with chronic pain following whiplash
injuries. European Journal of Pain, 14, 1059e1-1059e11.
Zettle, R. D., Rains, J. C. & Hayes, S. C. (in press). Processes of change in
Acceptance and Commitment Therapy and Cognitive Therapy for depression: A
mediational reanalysis of Zettle and Rains (1989). Behavior Modification.

Evidence that ACT works by different processes than

standard Cognitive Behavior Therapy (CBT) and other common
interventions

Several of the available studies allow us to examine whether ACT works by different
mechanisms than other interventions. There are two general classes of studies relevant to this
issue; those studies that compare ACT to a variety of educational or supportive interventions,
and those studies that compare ACT to a form of cognitive therapy. Four studies have shown
that ACT works differently than educational lectures for reducing prejudice (Hayes, et al.,
2004a; Lillis, et al., 2007), increasing willingness among counsellors to use empirically
supported treatments (Varra, et al., 2008), and self-care in diabetes (Gregg, et al., 2007). Two
other studies suggest that ACT works by different processes than supportive therapy
(Lundgren, et al., 2008) and different processes than an intervention that teaches people to
modify workplace stressors (Bond, et al., 2000). These studies generally show that while
ACT increases psychological flexibility, educational lectures and supportive interventions do
not.
Seven studies have compared ACT to a form of cognitive therapy (CT). ACT was
better than CT at decreasing avoidant coping amongst cancer patients (Branstetter, et al.,
2004). ACT has been shown to be better than CT at improving psychological flexibility
(AAQ) amongst government employees (Flaxman, 2006), university students with anxiety or
depression (Forman, 2007), people recruited from the general public with mood and
interpersonal problems (Lappalainen, et al., 2007), and people with clinical depression
(Zettle, et al., 1986; Zettle, et al., 2009).
One possible explanation for the general pattern of differences between ACT and CT
is that ACT is simply better at influencing any process measure, regardless of whether it is
ACT consistent or inconsistent. However, three studies appear to be inconsistent with this

hypothesis. Dalrymple and Herbert (2007) showed that ACT improved psychological
flexibility but did not improve skill at controlling private experience, an ACT incongruent
process. Forman (2007) showed that CBT, but not ACT, improved observing and describing
components of mindfulness. Lappalainen et al. (2007) showed that ACT improved
psychological flexibility, whereas CBT improved self-confidence.
The results of Flaxman (2006) are somewhat more complicated but generally support
the notion that ACT and CT work by distinct processes. Both the ACT group and the stress
inoculation group (SIT, a form of cognitive therapy) produced improvements in ACT
consistent measures (psychological flexibility) and CT consistent measures (dysfunctional
attitudes). Flaxman (2006) conducted mediational analyses that looked at the unique
influence of psychological flexibility and dysfunctional attitudes and found that
psychological flexibility was the primary mediator in the ACT condition. In contrast,
psychological flexibility did not mediate the SIT outcomes, and there was some evidence that
dysfunctional cognitions mediated the effect of SIT between times 1 and 3 (but not between
times 1 and 2).
In a recent study, Brown, Gaudiano, and Miller (2011) surveyed second (e.g.CBT)
and third wave (e.g., ACT) cognitive behavioural therapists concerning the techniques they
used in therapy. There were differences between the two groups, with third-wave therapists
reporting greater use of exposure and second-wave therapists reporting greater use of
cognitive restructuring and relaxation techniques.
How to learn more about ACT

The association for contextual behavioural science

This is the main organization for ACT. It has a webpage with lots of clinical resources and
announcements of upcoming events.

http://www.contextualpsychology.org/

ACT listserves

There are two internet groups, the international group, and the Australian and new Zealand
group. These provide a forum for people to discuss ACT and to announce upcoming events.

International list server

acceptanceandcommitmenttherapy-subscribe@yahoogroups.com

Australian and New Zealand List server

acceptanceandcommitmenttherapy_ANZO-subscribe@yahoogroups.com

References

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Bilich, L. and Ciarrochi, J. (2009) 'Evaluating Acceptance and Commitment
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