Behaviour Research and Therapy 104 (2018) 14–33

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Behaviour Research and Therapy

journal homepage: www.elsevier.com/locate/brat

A meta-analysis of dropout rates in acceptance and commitment therapy T

∗
Clarissa W. Ong , Eric B. Lee, Michael P. Twohig
Department of Psychology, Utah State University, 2810 Old Main Hill, Logan, UT 84322, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Many psychotherapies, including cognitive behavioral therapy and acceptance and commitment therapy (ACT),
Meta-analysis have been found to be effective interventions for a range of psychological and behavioral health concerns.
Dropout Another aspect of treatment utility to consider is dropout, as interventions only work if clients are engaged in
Acceptance and commitment therapy them. To date, no research has used meta-analytic methods to examine dropout in ACT. Thus, the objectives of
the present meta-analysis were to (1) determine the aggregate dropout rate for ACT in randomized controlled
trials, (2) compare dropout rates in ACT to those in other psychotherapies, and (3) identify potential moderators
of dropout in ACT. Our literature search yielded 68 studies, representing 4,729 participants. The weighted mean
dropout rates in ACT exclusive conditions and ACT inclusive conditions (i.e., those that included an ACT in-
tervention) were 15.8% (95% CI: 11.9%, 20.1%) and 16.0% (95% CI: 12.5%, 19.8%), respectively. ACT dropout
rates were not significantly different from those of established psychological treatments. In addition, dropout
rates did not vary by client characteristics or study methodological quality. However, master's-level clinicians/
therapists (weighted mean = 29.9%, CI: 17.6%, 43.8%) were associated with higher dropout than psychologists
(weighted mean = 12.4%, 95% CI: 6.7%, 19.4%). More research on manipulable, process variables that influ-
ence dropout is needed.

1. Introduction
Treatment dropout rates for psychotherapy have been examined in a
number of reviews. An early systematic review of psychotherapy
dropout rates across 125 studies published before 1990 concluded that
46.9% of participants dropped out of treatment prematurely
(Wierzbicki & Pekarik, 1993). A more recent review found an improved
dropout rate of 19.7% across 669 studies published from 1990 to 2010
(Swift & Greenberg, 2012). Dropout rates for the different types of
treatment were: 17.3% (supportive therapy), 18.4% (cognitive beha-
vioral therapy; CBT), 19.1% (integrative), 19.2% (solution-focused),
and 20.0% (psychodynamic). However, no significant differences in
dropout rates were found among modalities. Another recent review of
115 CBT clinical trials found dropout rates of 15.9% before the start of
treatment and 26.2% during treatment (Fernandez, Salem, Swift, &
Ramtahal, 2015).
Although informative, these meta-analytic reviews have not speci-
fically examined dropout rates in modern forms of CBT. One such un-
examined treatment modality is acceptance and commitment therapy
(ACT; S. C. Hayes, Strosahl, & Wilson, 1999), a type of cognitive be-
havioral therapy that emphasizes acceptance, mindfulness, and valued
action. The theorized mechanism of change in ACT is psychological
flexibility, which can be defined as the ability to fully contact the
present moment regardless of internal experiences that show up, while
engaging in valued behavior (S. C. Hayes, Luoma, Bond, Masuda, &
Lillis, 2006). ACT aims to improve psychological flexibility through six
processes or skills, with the ultimate aim of increasing effective or
meaningful action. The ACT processes include: acceptance (willingness
to experience internal events), defusion (deliteralizing language that
can govern behavior), contact with the present moment (grounding the
self in the here and now), self-as-context (recognizing the self as a
temporary vessel for internal events), values (self-chosen domains of
living that provide meaning and purpose), and committed action
(commitment to and engagement in valued behavior).
A growing body of research has shown ACT to be an effective
treatment across a broad range of problem areas that include: anxiety
(Swain, Hancock, Hainsworth, & Bowman, 2013), chronic pain (Hann &
McCracken, 2014), depression (Zettle, 2015), obsessive-compulsive
spectrum disorders (Bluett, Homan, Morrison, Levin, & Twohig, 2014),
and substance use (Lee, An, Levin, & Twohig, 2015). However, little is
known about the overall acceptability of ACT and how it compares to
that of other empirically supported treatments.
As ACT becomes more established and popular among treatment
providers, it is increasingly necessary to evaluate dropout rates in ACT.
ACT emphasizes a willingness to experience thoughts, emotions, and
bodily sensations, eschewing more traditional methods of evaluating

∗
Corresponding author.
E-mail address: clarissa.ong@usu.edu (C.W. Ong).

https://doi.org/10.1016/j.brat.2018.02.004
Received 21 August 2017; Received in revised form 2 January 2018; Accepted 13 February 2018
Available online 16 February 2018
0005-7967/ © 2018 Elsevier Ltd. All rights reserved.
C.W. Ong et al.
and attempting to change, remove, or control these experiences (e.g.,
cognitive restructuring). These strategies are used in other psy-
chotherapies, such as CBT. The theory, philosophy, and methodology of
ACT may be better suited to some individuals, whereas others may
more readily engage in a traditional CBT approach. For example, a
recent analysis of two randomized controlled trials identified mod-
erators that differentiated between participants who were more likely
to continue treatment for anxiety using either a traditional CBT or ACT
approach (Niles, Wolitzky-Taylor, Arch, & Craske, 2017). The re-
searchers found that those who perceived a high level of control of their
anxiety, were taking medication for anxiety, were more religious, and
were more avoidant of physiological arousal symptoms were more
likely to drop out of ACT than CBT. On the other hand, individuals were
more likely to drop out of CBT than ACT when they did not have these
traits. A better understanding of predictors of dropout in ACT could be
used to individualize treatment recommendations among the many
empirically supported therapies, as well as identify variables that en-
hance treatment retention in ACT, consequently, bolstering treatment
effectiveness.
The overarching objective of the current meta-analysis was to ex-
amine dropout in ACT, as one of the key metrics of treatment utility. As
such, the specific goals of our study were to: (1) systematically and
statistically review current data on dropout rates in ACT across a broad
range of psychological and behavioral health problems, (2) compare
dropout rates in ACT to those in other psychological interventions, and
(3) identify potential moderating factors that contribute to dropout in
ACT, including client characteristics and therapy variables.
2. Method
This meta-analysis was conducted in accordance with the PRISMA
guidelines (Moher, Liberati, Tetzlaff, Altman, & The PRISMA Group,
2009).
2.1. Literature search
Systematic literature searches were conducted on PsycINFO and
PubMed in August 2017, using the keywords: “acceptance and com-
mitment therapy” AND “randomized controlled trial OR RCT OR
random*.” Search results were restricted to peer-reviewed journal ar-
ticles published in English. We also identified articles from a list of ACT
randomized controlled trials on the Association for Contextual
Behavioral Science website, which was updated in March 2017
(https://contextualscience.org/ACT_Randomized_Controlled_Trials).
After the removal of duplicate articles, abstracts were screened by the
first and second authors. Full-length articles of abstracts that appeared
to meet the study selection criteria were retrieved. The articles were
then reviewed for eligibility. Any ambiguity regarding study eligibility
was settled via discussion between the first two authors; a consensus
was required for inclusion in the meta-analysis.
2.2. Selection criteria
To be included in the present meta-analysis, studies had to meet the
following criteria: (a) random assignment to treatment condition; (b)
inclusion of at least one comparison condition (e.g., waitlist, treatment-
as-usual); (c) participants with a psychological diagnosis, physical di-
agnosis, or behavioral health problem (i.e., clinical sample); (d) com-
prehensive ACT protocol (i.e., covered all six ACT processes); (e) face-
to-face therapy; and (f) English-language publication. We included
various modalities of therapy, including individual, group, and tele-
health formats, as well as participants belonging to all age groups to
increase generalizability of our findings. Studies that reanalyzed data
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Behaviour Research and Therapy 104 (2018) 14–33
from an existing study, used a treatment that did not match the iden-
tified problem behavior (e.g., targeting shame in individuals with
substance use), or that did not provide sufficient information on
dropout rates were excluded from this review.
2.3. Risk of bias in individual studies
To increase generalizability of present findings, we did not exclude
studies based on methodological quality, provided that they met our
eligibility criteria. We note that heterogeneity in reported dropout rates
may be partly attributed to methodological quality, which we examined
as a moderator. However, the variance introduced by study quality may
also provide a more accurate representation of psychological inter-
ventions administered across different settings.
2.4. Coding
Methodological quality. Given our broad inclusion criteria, each
study was coded for methodological quality by two independent raters
using the Psychotherapy Outcome Study Methodology Rating Scale
developed by Öst (2008), which has been used in previous meta-ana-
lyses (A-Tjak et al., 2015; Öst, 2014). The scale assesses outcome stu-
dies in the areas of: clarity of sample description, disorder severity/
chronicity, sample representativeness, diagnostic reliability, specificity
of outcome measures, psychometric quality of outcome measures, use
of blind evaluators, assessor training, condition assignment, design
(strength of comparison conditions), power analysis, assessment points,
quality and replicability of intervention, number of therapists, therapist
training/experience, checks for treatment adherence, checks for
therapist competence, control of concomitant treatments, handling of
attrition, statistical analyses and presentation of findings, clinical sig-
nificance, and equality of therapy hours across conditions. Each area is
rated from 0 (poor) to 2 (good), and verbal descriptions of each nu-
merical score are provided in the scale. The intraclass correlation
coefficient for total score between both raters was .99 (95% CI:
.99–1.00), indicating excellent interrater reliability.
Descriptive information. Data on participant and treatment
characteristics, as well as dropout rates were extracted from each ar-
ticle. For analyses, we defined dropout as attrition following the start of
therapy (i.e., after attending at least one session of intervention).
Trained research assistants coded all studies, and 85% of articles were
recoded by a second coder for accuracy. Discrepancies in coding were
resolved by either the first or second author.
Samples were coded by age group (adult, child/adolescent) and
diagnosis (psychological, physical, behavioral health, mixed).
Psychological conditions included presentations such as anxiety, de-
pression, and eating disorders; physical conditions included chronic
pain and fibromyalgia; and behavioral health conditions included
substance use and obesity. Study conditions were categorized into
treatment type (ACT [ACT exclusive], ACT+ [ACT plus another inter-
vention or ACT inclusive], CBT, cognitive therapy [CT], behavior
therapy [BT], active control, inactive control), therapy format (in-
dividual, group, mixed), mode of delivery (in-person, telehealth), and
therapist experience (Ph.D./psychologist, M.D./physician, Master's
level clinician/therapist, graduate student, no therapist, multi-
disciplinary team). Active control conditions included treatment as
usual, whereas inactive control referred to waitlist conditions. When
conditions used therapists with varying levels of experience within the
same domain (e.g., psychologists and psychology graduate students),
they were assigned to the category with less experience (i.e., graduate
students) to err on the conservative side.
C.W. Ong et al. Behaviour Research and Therapy 104 (2018) 14–33

Identification
Records identified through Additional records identified
database searching through ACBS list of ACT RCTs
(n = 455) (n = 182)

Records after duplicates removed

(n = 342)
Screening

Records screened Records excluded

(n = 342) (n = 265)

Full-text articles excluded

(n = 20)
Full-text articles Non-random assignment
(1)
Eligibility

assessed for eligibility

(n = 88) Non-clinical sample (4)
Treatment protocol did
not cover all ACT
processes or was
inconsistent with ACT (2)
Too few treatment
sessions (4)
Studies included in Data reported elsewhere
Included

quantitative synthesis (3)

(meta-analysis) Insufficient data on
(n = 68) dropout (4)
Description of study
protocol (2)

Fig. 1. Flowchart of literature search process. ACT = acceptance and commitment therapy; ACBS = Association for Contextual Behavioral Science; RCT = randomized controlled trial.

2.5. Analytic plan
Statistical analyses were conducted using R version 3.4.0 (R Core
Team., 2015), and the R packages: tidyverse (Wickham, 2017) and
metafor (Viechtbauer, 2010). Proportion data were first transformed
using the Freeman-Tukey (double arcsine) transformation. This trans-
formation is recommended for proportion data because it produces
more stable estimates of corresponding sampling variances for the
sampling distribution of proportions close to 0 or 1 (Barendregt, Doi,
Lee, Norman, & Vos, 2013; Freeman & Tukey, 1950). The transformed
proportions and their corresponding sampling variances were used in
all analyses, and were back-transformed—based on the equation de-
rived by Miller (1978)—in cases of significance for ease of interpreta-
tion.
Weighted means (with inverse-variance weights) for dropout rates
were computed using random effects models. Random effects models
were selected given heterogeneity in study findings as indicated by
Cochran's Q test (Cochran, 1954) and the I2 statistic (Higgins &
Thompson, 2002; Higgins, Thompson, Deeks, & Altman, 2003).
A metaregression with study condition as the predictor and dropout
rate as the dependent variable was used to determine if dropout differed
by treatment type. A second metaregression tested the effects of client
characteristics (i.e., age group and diagnosis) on dropout rate in ACT. A
third metaregression was conducted with therapy format, therapist
experience, session count, and session frequency as predictors to iden-
tify potential therapeutic moderators of dropout in ACT. A fourth me-
taregression examined the effect of study methodological quality on
dropout in ACT. Finally, a funnel plot with trim and fill as well as the
random effects version of the Egger's regression test for funnel plot
asymmetry were used to evaluate publication bias in our data (Duval &
Tweedie, 2000; Egger, Smith, Schneider, & Minder, 1997).

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Table 1
Characteristics of included studies.

All studies (k = 68) ACT exclusive conditions (n = 56) ACT inclusive conditions (n = 71)

Age group
Adult 64 (94.1%) 51 (91.1%) 66 (93.0%)
Adolescent/child 4 (5.9%) 5 (8.9%) 5 (7.0%)
Diagnosis
Psychological 36 (52.9%) 29 (51.8%) 37 (52.1%)
Physical 21 (30.9%) 19 (33.9%) 23 (32.4%)
Behavioral health 9 (13.2%) 6 (10.7%) 9 (12.7%)
Mixed 2 (2.9%) 2 (3.6%) 2 (2.8%)
Conditiona
ACT 56 (38.4%) 56 (100%) 56 (78.9%)
ACT+ 15 (10.3%) 15 (21.1%)
CBT 13 (8.9%)
CT 2 (1.4%)
BT 3 (2.1%)
Active control 33 (22.6%)
Inactive control 24 (16.4%)
Therapy formata
Individual 54 (50.9%) 30 (54.5%) 35 (51.5%)
Group 39 (36.8%) 22 (40.0%) 26 (38.2%)
Mixed 13 (12.3%) 3 (5.5%) 7 (10.3%)
Modea
In-person 104 (98.1%) 54 (98.2%) 68 (98.6%)
Telehealth 2 (1.9%) 1 (1.8%) 1 (1.4%)
Therapist experiencea
Ph.D./Psychologist 17 (14.0%) 11 (25.0%) 13 (23.2%)
M.D./Physician 6 (5.0%) 1 (2.3%) 1 (1.8%)
Master's level clinician/therapist 18 (14.9%) 8 (18.2%) 10 (17.9%)
Graduate student 33 (27.3%) 17 (38.6%) 22 (39.3%)
No therapist 30 (24.8%) 0 (0%) 0 (0%)
Multidisciplinary team 17 (14.0%) 7 (15.9%) 10 (17.9%)
Session counta 11.5 (7.4) 11.3 (4.6) 11.6 (6.5)
Session frequency (per week on average)a 1.2 (0.8) 1.0 (0.3) 1.1 (0.5)
Methodological quality 20.8 (7.3)

a
Reflects condition-level data.

3. Results
3.1. Study selection
Fig. 1 summarizes the literature search process. A total of 637 ar-
ticles were identified from initial searches, and 342 unique abstracts
were reviewed for eligibility. Among those abstracts, 88 full-length
articles were selected for more thorough review. Ultimately, 68 re-
search articles, representing 4729 participants, were included in the
present meta-analysis.
15.8% (95% CI: 11.9%, 20.1%, range = 0–84.9%, Q[55] = 283.44
[p < .001], I2 = 78.75%, k = 56). When ACT inclusive conditions
(i.e., all those that included an ACT intervention) were considered, the
weighted mean dropout rate was 16.0% (95% CI: 12.5%, 19.8%,
range = 0–84.9%, Q[70] = 365.26 [p < .001], I2 = 78.73%, k = 71).
Figs. 2 and 3 are forest plots that represent condition-level dropout
rates and corresponding 95% confidence intervals for the ACT exclusive
and ACT inclusive (without ACT exclusive) conditions, respectively. To
eliminate the confounding effects of an intervention other than ACT,
the following results pertain to ACT exclusive conditions.

3.2. Descriptive information

Study characteristics are presented in Table 1. The majority of
studies used adult samples, psychological conditions, individual
therapy, and in-person format. Most ACT sessions were conducted by
psychologists and graduate students (see Appendix for a detailed de-
scription of included studies).
3.3. Dropout rates in ACT
The weighted mean dropout rate in ACT exclusive conditions was
3.4. Treatment condition comparison
The metaregression revealed no significant differences in dropout
rates among conditions (ps > .05). The differences between ACT and
CBT (weighted mean = 25.3%, 95% CI: 16.9%, 34.8%, p = .052), as
well as between ACT and inactive control (weighted mean = 9.5%,
95% CI: 5.6%, 14.1%, p = .072) were notable, but not statistically
significant (see Table 2). Specifically, ACT was associated with a lower
dropout rate than CBT, and with a higher dropout rate than inactive
control conditions.

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C.W. Ong et al. Behaviour Research and Therapy 104 (2018) 14–33

Fig. 2. Forest plot of dropout rates and corresponding 95% confidence intervals for acceptance and commitment therapy exclusive conditions.

3.5. Predictors of dropout
Neither age group nor client diagnosis significantly predicted
dropout rate in ACT (ps > .05; see Table 3). There was a nonsignificant
difference between the dropout rate for behavioral health problems
(weighted mean = 27.2%, 95% CI: 9.2%, 49.8%) compared to that for
psychological conditions (weighted mean = 16.4%, 95% CI: 11.0%,
22.5%, p = .098), with higher dropout observed for behavioral health
problems.
Therapy format, session count, and session frequency did not

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C.W. Ong et al. Behaviour Research and Therapy 104 (2018) 14–33

Fig. 3. Forest plot of dropout rates and corresponding 95% confidence internals for acceptance and commitment therapy inclusive conditions.

Table 2
Results from metaregression analysis of treatment conditions on dropout.

Moderator (k) Dropout rate 95% CI z p

a
ACT exclusive (56) 15.8% 11.9%, 20.1%
ACT inclusive (15) 16.7% 9.1%, 25.8% 0.28 .776
Cognitive behavioral therapy (13) 25.3% 16.9%, 34.8% 1.94 .052
Cognitive therapy (2) 5.3% 0.9%, 11.8% −0.95 .342
Behavior therapy (3) 17.7% 9.9%, 26.8% 0.01 .993
Active control (32) 17.4% 12.7%, 22.6% 0.47 .638
Inactive control (24) 9.5% 5.6%, 14.1% −1.80 .072

Note. ACT = acceptance and commitment therapy; CI = confidence interval.

a
Reference level in metaregression.

Table 3
Results from metaregression analysis of client, therapy, and study moderators on dropout in ACT.

Moderator (k) Dropout rate 95% CI z p

Age group
Adulta (51) 15.3% 11.2%, 19.8%
Adolescent/child (5) 21.4% 11.2%, 33.6% 1.12 .264
Diagnosis
Psychologicala (29) 16.4% 11.0%, 22.5%
Physical (19) 12.1% 7.5%, 17.5% −1.16 .246
Behavioral health (6) 27.2% 9.2%, 49.8% 1.65 .098
Mixed (2) 14.0% 7.7%, 21.5% −0.26 .792
Therapy format
Individuala (30) 16.0% 11.2%, 21.4%
Group (22) 12.8% 9.0%, 17.1% 0.57 .569
Mixed (3) 45.7% 7.2%, 87.4% 0.62 .535
Therapist experiencea
Ph.D./Psychologista (11) 12.4% 6.7%, 19.4%
M.D./Physician (1) 26.7% 6.8%, 52.3% 1.04 .296
Master's level clinician/therapist (8) 29.9% 17.6%, 43.8% 2.35 .019
Graduate student (17) 15.6% 11.0%, 20.7% 0.68 .498
Multidisciplinary team (7) 13.1% 5.7%, 22.6% 0.31 .760
Session count – – 0.73 .464
Session frequency (per week on average) – – 1.03 .305
Methodological quality – – 0.76 .447

Note. ACT = acceptance and commitment therapy; CI = confidence interval.

a
Reference level in metaregression.

19
C.W. Ong et al.
Fig. 4. Funnel plot with transformed proportions on the x-axis and their corresponding sampling variances on the y-axis, with missing studies filled in using the trim and fill method.
significantly predict dropout rate in ACT (ps > .20; see Table 3). Re-
lative to by psychologists (weighted mean = 12.4%, 95% CI: 6.7%,
19.4%), ACT administered by master's-level clinicians/therapists were
associated with a higher dropout rate (weighted mean = 29.9%, 95%
CI: 17.6%, 43.8%, p = .019). However, no differences were found be-
tween psychologists and graduate students (weighted mean = 15.6%,
95% CI: 11.0%, 20.7%, p = .50) or multidisciplinary teams (weighted
mean = 13.1%, 95% CI: 5.7%, 22.6%, p = .76).
Study methodological quality was also tested as a potential mod-
erator of dropout in ACT conditions, given the heterogeneity of study
design and quality included in this review. There was no significant
effect of methodological quality on dropout in ACT (p = .45).
3.6. Publication bias
Fig. 4 shows a funnel plot representing the distribution of trans-
formed dropout rates in ACT exclusive conditions, with missing studies
represented by blank circles using the trim and fill method (Duval &
Tweedie, 2000). The transformed dropout rates are positively corre-
lated with actual dropout rates, and so can be interpreted similarly. The
funnel plot depicts slight asymmetry; conditions with lower trans-
formed rates across the range of sampling variances tended to be
overrepresented, implying that our sample may be biased in the di-
rection of excluding studies with higher dropout rates. This visual ob-
servation was corroborated by results from the Egger's regression test,
which indicated that the funnel plot was significantly asymmetrical
(p < .05). These results suggest that the aggregate figures reported
could be an underestimation of “true” dropout rate.
4. Discussion
The purpose of the present study was to examine dropout rates in
ACT, how they compare to those in other psychological interventions,
as well as moderators of dropout in ACT. Given previous research that
has demonstrated no differences in treatment effectiveness between
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Behaviour Research and Therapy 104 (2018) 14–33
ACT and CBT (A-Tjak et al., 2015), determining treatment dropout
provides another metric of the practical utility of ACT. We found that
the dropout rate for ACT exclusive conditions was 15.8%, and the rate
for ACT inclusive conditions was 16.0%. Both figures are close to those
reported for other interventions, including adult psychotherapies (e.g.,
CBT, psychodynamic; 19.7%; Swift & Greenberg, 2012), CBT for mental
health concerns (26.2%; Fernandez et al., 2015), individual psy-
chotherapy for major depression (19.9%; Cooper & Conklin, 2015), and
exposure and response prevention for obsessive-compulsive disorder
(14.7%; Ong, Clyde, Bluett, Levin, & Twohig, 2016). The observed
consistency between dropout rates in ACT, an acceptance- and mind-
fulness-based CBT, and other psychotherapies coheres with a previous
meta-analysis that found no significant differences in dropout across
treatment orientations (Swift & Greenberg, 2012).
The heterogeneity in dropout rates indicated by Cochran's Q tests
and I2 statistics suggested the presence of moderating variables. Yet, we
only identified one significant moderator of dropout: therapist experi-
ence. Specifically, ACT administered by master's-level clinicians sig-
nificantly predicted higher rates of dropout (26.4%) than when therapy
was conducted by psychologists (12.6%). Findings on therapist ex-
perience as a moderator have been mixed, with two meta-analyses in-
dicating no significant effect (Cooper & Conklin, 2015; Fernandez et al.,
2015) and one reporting higher dropout rates when trainees (working
toward a degree) provided the intervention (Swift & Greenberg, 2012).
Of note, our analyses did not reveal a significant difference between
psychologist and graduate student therapists. As graduate students are
required to work under a licensed clinical psychologist, it is possible
that the continued supervision maintained treatment integrity. How-
ever, replication of this result in other settings is warranted before
strong inferences can be made.
The overall lack of significant findings could have been due to lack
of power, as a previous meta-analysis reported that diagnostic group
and number of sessions significantly predicted dropout in CBT across
115 and 89 studies, respectively (Fernandez et al., 2015). Alternatively,
factors that were not assessed consistently across studies, such as
C.W. Ong et al.
therapeutic alliance—and that were hence excluded from our analy-
ses—could have explained the variability in dropout (Cooper et al.,
2016). Initial metrics like this are important to form a base for future
researchers to continue to study similar issues.
The range of diagnostic concerns represented in our sample reflects
the flexibility of ACT treatment protocols used across studies, given that
the same six processes were used to target a variety of clinical pre-
sentations. It is thus possible that the transdiagnostic nature of ACT,
which leads to topographical differences in the presentation of therapy
even within the same study, also contributed to the variability in
dropout rate. For example, an established ACT protocol used in an RCT
for OCD explicitly instructs therapists to introduce ACT processes in a
flexible manner, based on clients’ presenting concerns (Twohig et al.,
2010). A closer examination of how therapy is actually carried out (e.g.,
order in which processes are introduced, functionality of therapist re-
sponse)—perhaps through viewing and coding therapy sessions—might
elucidate the critical elements that lead to premature termination.
It is worth briefly discussing the treatment condition and diagnostic
group modifiers that were notable, yet not statistically significant. The
higher dropout rate of CBT compared to ACT conditions (24.9% vs.
15.8%) was close to that reported by Fernandez et al. (2015) of 26.2%,
thus, it is unlikely that the difference was due to therapist allegiance.
Rather, it might be that the relative nascence of ACT as an intervention
circumscribed its application to research labs focused on ACT, with
clinicians well trained in ACT conducting the intervention. It is possible
that dropout rates will change as the use of ACT proliferates. In addi-
tion, the lower dropout rate in inactive control conditions (9.5% vs.
15.8%) could be attributed to lower participant burden in terms of time
and effort, given that participants were not required to attend any
sessions at all. Finally, behavioral health problems tended to predict
more dropout than psychological conditions (25.5% vs. 15.4%). This
could be because substance use (e.g., cigarette smoking, opioid de-
pendence) were coded as behavioral health problems. Interventions for
substance use disorders are reported to be commonly associated with
high dropout, with rates reaching as high as 90.4% (Brorson, Arnevik,
Rand-Hendriksen, & Duckert, 2013; Kern-Godal, Arnevik, Walderhaug,
& Ravndal, 2015); this pattern might have been reflected in our results.
Still, inclusion of more studies and increased statistical power are
needed to more accurately estimate the effects of these modifiers on
dropout.
Our findings suggest that, in addition to comparable effectiveness of
ACT to established treatments (A-Tjak et al., 2015), ACT also shows
comparable dropout rates. Individual studies have demonstrated high
acceptability of ACT based on participant ratings (e.g., Johns et al.,
2016; Twohig et al., 2010), and this meta-analysis corroborates pre-
liminary indicators of client-reported acceptability using a behavioral
metric. Still, the lack of information on moderators underscores the
need for more systematic collection and reporting of data using stan-
dardized, psychometrically validated measures on process of change
variables that have been shown to influence dropout, such as ther-
apeutic alliance and use of behavioral strategies and homework
(Cooper et al., 2016; Sharf, Primavera, & Diener, 2010), as well as other
potentially relevant variables, such as client-reported treatment ac-
ceptability and treatment manual adherence. Doing so may facilitate
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Behaviour Research and Therapy 104 (2018) 14–33
moderation analyses in future meta-analyses. Furthermore, identifying
manipulable aspects of treatment that reduce probability of dropout can
guide the development of more acceptable interventions. Attending to
such factors—beyond those that contribute to greater treatment effi-
cacy—is important because the most effective interventions are ren-
dered futile by premature termination.
4.1. Limitations
First, our exclusive focus on RCTs limits generalizability of our
findings to other settings given that the nature of treatments provided
in research studies are not representative of how they are conducted in
clinical practice (e.g., time-limited course). Moreover, real-world set-
tings may introduce more client and treatment variables that increase
variability in dropout rates. Second, although we attempted to include
moderating variables that may be relevant to dropout (e.g., perceived
treatment acceptability, therapeutic alliance), insufficient data pre-
cluded such analyses. Furthermore, even when data were provided,
they were not based on the same or standardized scales, making com-
parison of scores difficult. Third, we only examined dropout rates based
on overall attrition due to limited availability of data in included stu-
dies. However, more comprehensive reporting on specific aspects of
attrition (e.g., point in therapy at which participants drop out, reasons
for dropout) may provide insight into differential factors that influence
dropout. Fourth, the weighted aggregate dropout rate in ACT might not
have been derived from a balanced sample of clinical trials, and it is
possible that dropout rates are higher than reported. The “file drawer
problem” is a well-documented source of publication bias that may
undermine the accuracy of meta-analytic findings as significant findings
are more likely to be published than nonsignificant findings (Rosenthal,
1979). It is plausible that such bias may apply to dropout rates as well,
such that studies with higher dropout rates are less likely to be pub-
lished. The presence of this effect was supported by results from the
Egger's regression test as well as our funnel plot (see Fig. 4). Hence,
current findings should be considered conservative estimates of actual
dropout rates. Finally, authors used varying definitions of dropout,
which necessarily imbues our metadata with inconsistency. In certain
studies, only those who completed all intervention sessions were con-
sidered completers, whereas others considered participants who com-
pleted more than half of the prescribed course of treatment completers.
Greater clarity in reporting (e.g., breakdown of treatment completion
progress) would facilitate more accurate data extraction.
Funding source
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Statement of competing interests
The authors have no competing interests to declare.
 Appendix
C.W. Ong et al.

Qualitative Description of Included Studies.

Year Authors Sample description N Gender Mean age SD age Ethnicity Treatment condition Therapist Session Session Session
(% (years) (years) (% White) experience count frequency length
female) (minutes)

2002 Bach & Hayes Adults 80 36.3 39.4 – 75 ACT + TAU Psychologist or 4 First within 45–50
experiencing psychology 72 h of
auditory intern agreeing to
hallucinations or participate,
delusions at the second within
time of their 72 h of first,
admission to a state third held 3–5
psychiatric hospital days after
second, and
fourth within
72 h of
discharge
TAU Psychologist or 3+ 1 or 2/week 40
psychology

22
intern
2004 Dahl, Wilson, & Swedish public 19 89.5 40 13.2 – MTAU + ACT CBT 4 1/week 60
Nilsson health service psychotherapist
employees and registered
experiencing daily nurse
pain or stress MTAU – – – –
symptoms that
were attributed to
work
2004 Gifford et al. Self-identified 76 59 43 11.68 77 ACT Psychologist and 14 2/week 50
nicotine-dependent graduate (individual),
adult smokers students 90 (group)
smoking 10 Nicotine replacement Psychiatrist and 1 1, with 90
cigarettes or more treatment psychiatry individual
per day for at least resident consultation
12 months if
nonadherent
Behaviour Research and Therapy 104 (2018) 14–33
 2004 Hayes et al. Adults with DSM- 124 51 42.2 Range = 23 87 ACT + methadone Therapists with 32 3/week 60
IV diagnosis of to 64 maintenance at least 2 years individual, (individual),
substance abuse or of experience in 16 group 90 (group)
dependence and the treatment of
C.W. Ong et al.

had relapsed to substance abuse

that substance and in use of
during the last 30 behavior
days therapy
Intensive Twelve-Step Therapist with 32 3/week 60
Facilitation + methadone at least 5 years' individual, (individual),
maintenance experience in 16 group 90 (group)
the treatment of
substance abuse,
sponsor
Methadone maintenance – – – –
2006 Gratz & Adult women 22 100 33.32 9.98 100 Emotion regulation group – 14 1/week 90
Gunderson meeting five or intervention + TAU
more criteria for TAU NA NA NA NA
BPD
2006 Lundgren, Adults with 27 51.85 40.675 – – ACT + epilepsy control Psychologists 4 – 90
Dahl, Melin & medical diagnosis and institution individual, (individual),
Kies of epilepsy staff 2 group 180 (group)
Supportive therapy Psychologists 4 – 90
and institution individual, (individual),
staff 2 group 180 (group)

23
2006 Woods, Adults with DSM- 28 89.28 34.6 9.8 96.4 ACT + habit reversal Master's-level 10 1/week, then –
Wetterneck & IV diagnosis of training therapist 1/2 weeks
Flessner TTM Waitlist NA NA NA NA
2008 Roemer, Orsillo Adults with 31 71 33.59 11.74 87.1 Acceptance-based Graduate 16 1/week 90 (4
& Salters- primary DSM-IV behavior therapy students sessions), 60
Pedneault diagnosis of GAD (12 sessions)
Waitlist NA NA NA NA
2008 Wicksell, Adults with 21 76.19 51.65 – Exposure and acceptance Psychologists 10 10 over 8 60
Ahlqvist, Bring, medical diagnosis 48.2 7.8 therapy and physician weeks
Melin & Olsson of whiplash 55.1 11.2 Waitlist NA NA NA NA
associated
disorders with pain
duration lasting
more than three
months
2009 Petersen & Adults with DSM- 24 50 36.7 11.5 62.5 ACT Graduate Until 2/week 30
Zettle IV alcohol abuse or student discharge
dependence and 38.9 7.8 TAU Counselors Until Based on 60
unipolar depressive discharge availability
disorder
Behaviour Research and Therapy 104 (2018) 14–33
 2009 Wicksell, Adolescents with 32 78.13 14.8 2.4 – ACT Psychologists 12 1/week 60 (10
Melin, pain duration of and physician sessions), 90
Lekander & more than 3 (2 sessions)
Olsson months Multidisciplinary Psychiatrist, 7 to 56 1/week Variable; 40-
C.W. Ong et al.

treatment approach psychologist, 60

physiotherapist,
and physician
2010 Smout et al. Adults (16 and up) 104 40 30.9 6.5 – ACT Psychologist and 12 1/week 60
with DSM-IV master's-level
criteria clinician
methamphetamine CBT Psychologist and 12 1/week 60
abuse or master's-level
dependence clinician
2010 Twohig et al. Adults with DSM- 79 61 37 15.5 88.6 ACT Graduate 8 1/week 60
IV diagnosis of students
OCD Progressive relaxation Graduate 8 1/week 60
training students
2011 Gifford et al. Adults who smoke 303 58.7 45.99 12.5 86.8 ACT and medication Master's-level 10 2/week –
15 + cigarettes a therapist and individual,
day for at least graduate 10 group
twelve months students
Medication NA NA NA NA
2011 Hayes, Boyd, & Adolescents 38 71.05 14.9 2.55 37 born in ACT Clinicians – – –
Sewell experiencing 81 14.61 3.1 Australia, 1 working under
moderate to severe from an psychiatrists,

24
depressive indigenous including
symptoms background psychologists,
social workers,
psychiatric
nurses, and
occupational
therapists.
56 15.49 1.35 CBT Clinicians – – –
working under
psychiatrists,
including
psychologists,
social workers,
psychiatric
nurses, and
occupational
therapists.
2011 Westin et al. Adults with 64 46.9 50.9 12.9 – ACT Psychologists 10 1/week 60 (session 2
primary diagnosis and graduate was 75)
of tinnitus students
Tinnitus retraining therapy Physician 1 1 with follow- 150
up
Waitlist NA NA NA NA
Behaviour Research and Therapy 104 (2018) 14–33
 2011 Wetherell, Adults at least 60 21 47.5 70.8 6.5 62.5 ACT Postdoctoral and 12 1/week 60
Afari, Ayers years old with a master's-level
et al. principal DSM-IV clinicians
diagnosis of GAD CBT Postdoctoral and 12 1/week 60
C.W. Ong et al.

master's-level
clinicians
2011 Wetherell, Adults with chronic 114 50.9 54.9 12.5 67.5 ACT Psychologists 8 1/week 90
Afari, Rutledge pain for at least 6 and graduate
et al. months student
CBT Psychologist and 8 1/week 90
graduate student
2011 White et al. Adults who met 27 22.22 33.57 8.63 96.3 ACT Psychologist 10 1/month 60
ICD-10 criteria for 34.54 10.97 TAU Psychiatrist and – – –
a psychotic community
disorder psychiatric
nurse or
occupational
therapist
2012 Arch et al. Adults with DSM- 128 52.3 37.93 11.7 67.2 ACT Graduate 12 1/week 60
IV diagnosis of at students
least one anxiety CBT Graduate 12 1/week 60
disorder students
2012 England et al. Adults with public 45 80 31.93 10.55 64.4 Acceptance-based Graduate 6 1/week 120
speaking anxiety exposure students
who met DSM-IV- Habituation-based Graduate 6 1/week 120

25
TR criteria for exposure students
nongeneralized
SAD
2012 Folke, Parling Adults with DSM- 35 88.2 43.24 9.46 100 ACT Graduate 1 1/week 60-90
& Melin IV diagnosis of students individual, (individual),
unipolar depressive 5 group 120–180
disorder (group)
Control (access to public – – – –
health services)
2012 Jensen et al. Adult females 43 100 45.6 6.4 – ACT Psychologists 12 1/week 90
diagnosed with and physician
fibromyalgia Waitlist NA NA NA NA
2012 Mo'tamedi, Female adults with 30 100 34.18 7.39 100% ACT Psychiatrist 8 1/week 90
Rezaiemaram, diagnosis of 37.87 8.74 Iranian MTAU Psychiatrist 8 1/week –
& Tavallaie primary chronic
(migraine and
tension-type)
headache
according to the
International
Classification of
Headache
Disorders
Behaviour Research and Therapy 104 (2018) 14–33
 2012 Morton, Adults with four or 41 92.68 – ACT + TAU Clinicians 12 1/week 120
Snowdon, more DSM-IV 90.5 35.6 9.33
Gopold, & criteria for BPD 95 34 9.02 TAU Public mental – – –
Guymer health services
C.W. Ong et al.

2012 Nordin & Adults diagnosed 21 76.19 43 (median) 36-45 (IQR) – ACT Psychologists 5 – –
Rorsman with MS with 48.5 38-55 (IQR) Relaxation training Psychologists 5 – –
elevated symptoms (median)
of depression and/
or anxiety
2012 Stotts et al. Adults with opioid 56 37.5 40.3 10.7 77 ACT Master's-level 24 1/week 50
dependence clinicians
undergoing 39.4 8.7 88 Drug counseling Master's-level 24 1/week 50
detoxification therapists
2013 Forman et al. Adults with a BMI 128 – 45.69 12.81 62.3 Acceptance-based Psychologists 30 1/week, then 75
between 27 and behavioral treatment and graduate 1/2 weeks
40 kg/m2 students
Standard behavioral Psychologists 30 1/week, then 75
treatment and graduate 1/2 weeks
students
2013 Hayes-Skelton, Adults with a 81 65.4 32.92 12.24 80.2 ACT Postdoctoral 16 1/week, 1/2 90 (4
Roemer, & principal DSM-IV fellows and weeks sessions), 60
Orsillo diagnosis of GAD graduate (12 sessions)
students
Applied relaxation Postdoctoral 16 1/week, 1/2 90 (4
fellows and weeks sessions), 60

26
graduate (12 sessions)
students
2013 Kocovski, Adults with DSM- 137 54 34 – 62 Mindfulness and Psychologist and 12 1/week 120
Fleming, IV-TR diagnosis of 49.06 34.94 12.53 70 acceptance-based group psychiatrist
Hawley, Huta, social anxiety therapy
& Antony disorder 52.83 32.66 9.07 53 Cognitive behavioral Psychologist and 12 1/week 120
group therapy psychiatrist
64.52 36.55 11.58 65 Waitlist NA NA NA NA
2013 Villagrá Lanza Adult female 31 100 32 6.2 – ACT – 16 1/week 90
& González inmates with Waitlist NA NA NA NA
Menéndez substance use
disorder
2013 McCracken, Adults with 73 68.5 58 12.8 97.3 ACT + TAU Psychologists 4 3/week, then 240
Sato & Taylor persistent pain for 1/week
longer than 3 TAU Physicians – – –
months
2013 Steiner, Female adults with 28 100 48.63 12.96 79.3 ACT – 8 1/week 60
Bogusch & fibromyalgia Pain management – 8 1/week 60
Bigatti education
2013 Wicksell et al. Female adults with 40 100 45.1 6.6 – ACT Psychologists 12 1/week 90
fibromyalgia and physician
Waitlist NA NA NA NA
Behaviour Research and Therapy 104 (2018) 14–33
 2014 Avdagic, Adults with DSM- 51 66.7 36.17 13.1 – ACT Psychologist and 6 1/week 120
Morrissey, & IV diagnosis of graduate student
Boschen GAD CBT Psychologist and 6 1/week 120
graduate student
C.W. Ong et al.

2014 Chowdhary & Adults with ICD-10 24 0 20–35 ACT + TAU – 8–10 2/week 60
Jahan (DCR) diagnosis of TAU – – – –
schizophrenia
2014 Clarke, Adults who had 61 67.21 43.46 12.35 – ACT Clinical 16 1/week 120
Kingston, received at least psychologists
James, one previous 8- CBT Clinical 16 1/week 120
Bolderson, & session course of psychologist,
Remington psychotherapy and nurse specialist,
had been re- counselor
referred
2014 Craske et al. Adults with DSM- 87 45.98 28.37 6.76 50.57 ACT Psychologists 12 1/week 60
IV diagnosis of and graduate
social phobia, students
generalized type CBT Psychologists 12 1/week 60
and graduate
students
Waitlist NA NA NA NA
2014 Gharaei- Adult women with 30 100 33.28 7.91 ACT – 8 1/week 60
Ardkani et al. diagnosis of 32.83 7.53 Control (no intervention) NA NA NA NA
chronic tension
headaches and

27
migraines
2014 Gonzalez- Adult female 37 100 33.59 7.5 – ACT Graduate 16 1/week 90
Menendez, inmates diagnosed student
Fernandez, with current abuse CBT Psychologist 16 1/week 90
Rodriguez, & or dependence
Villagra
2014 Luciano et al. Adults with 156 96.2 48.88 5.94 – ACT Psychologist 8 – 150
diagnosis of 47.77 5.87 Recommended NA NA NA NA
fibromyalgia pharmacological treatment
48.28 5.71 Waitlist NA NA NA NA
2014 Mojtabaie & Women with breast 30 100 – – 100% ACT – 8 – 45–60
Asghari cancer with Iranian Waitlist NA NA NA NA
depressive
symptoms
2014 Tamannaeifar, Adults with a 20 100 25.2 4.3 ACT – 12 2/week –
Gharraee, primary DSM-IV 24.7 4.2
Birashk, & diagnosis of major 25.7 4.4 CT – 12 2/week –
Habibi depressive disorder
2014 Vakili, Adults with DSM- 32 44.4 26.96 6.83 100% ACT Psychologist 8 – –
Gharraee, IV-TR diagnosis of Iranian SSRIs Psychiatrist – – –
Habibi, OCD ACT + SSRIs Psychologist and 8 – –
Lavasani & psychiatrist
Rasoolian
Behaviour Research and Therapy 104 (2018) 14–33
 2015 Eilenberg, Adults who met 126 70.63 36.25 8.75 – ACT Psychologists 10 – 180
Frostholm, diagnostic criteria Waitlist NA NA NA NA
Schroder, for severe health
Jensen, & Fink anxiety
C.W. Ong et al.

2015 Gaudiano et al. Adults with DSM- 13 54 50 17 15% Acceptance-based Psychologist 16 1/week –
IV diagnosis of Hispanic depression and psychosis
major depressive therapy + MTAU
disorder, severe Enhanced assessment and Community – – –
with psychotic monitoring + MTAU clinician
features, or
schizoaffective
disorder,
depressive type
2015 Gloster et al. Adults diagnosed 43 69.8 36.9 8.9 – ACT Graduate 8 2/week 90–120
with panic disorder students
or agoraphobia Waitlist NA NA NA NA
who have had one
or more previous
courses of
psychological and/
or pharmacological
treatment
2015 Kemani et al. Adults with 60 73.3 40.3 11.4 – ACT Psychologist and 12 1/week 90
unspecific pain for physician
at least six months Applied relaxation Psychologist 12 1/week 90

28
2015 Losada et al. Adult dementia 135 84.57 61.82 13.54 – ACT Psychologists 8 1/week 90
family caregivers and master's-
with significant level clinicians
depressive CBT Psychologists 8 1/week 90
symptoms and master's-
level clinicians
Psychoeducation – 1 NA 120
2015 Nasiri & Adults diagnosed 30 88 39.97 4.42 – ACT – 8 1/week 90
Kazemi- with chronic pain Waitlist NA NA NA NA
Zahrani
2016 Alonso- Adults at least 65 101 78.6 82.26 10 – ACT + selective – 9 1/week 120
Fernandez, years old with optimization
Lopez-Lopez, chronic compensation strategies
Losada, musculoskeletal Minimal support group – 1 NA 120
Gonzalez, & pain for at least six
Wetherell months
2016 Azkhosh, Adult opiate 60 – 27.5 – – ACT Ph.D. 12 1/week 90
Farhoudianm, dependents TAU (Narcotics – – – –
Saadati, admitted to a drug Anonymous)
Shoaee, & rehab center TAU (methadone – – – –
Lashani replacement)
Behaviour Research and Therapy 104 (2018) 14–33
 2016 Crosby & Adults with 28 0 29.3 11.4 92 ACT Psychologist and 12 1/week 60
Twohig problematic graduate
pornography use students
Waitlist NA NA NA NA
C.W. Ong et al.

2016 Dixon, Wilson, Adults scoring 3 or 18 0 19.06 0.85 33 ACT – 8 1/week 60

& Habib higher on the South Waitlist NA NA NA NA
Oaks Gambling
Screen
2016 Eilenberg, Fink, Adults who met 126 70.5 36.25 8.75 – ACT – 10 1/week, then 180
Jensen, Reif, & diagnostic criteria 1/month
Frostholm for severe health Waitlist NA NA NA NA
anxiety
2016 Fogelkvist, Patients with an ED 53 100 Range = 18 – – ACT – 2 1/week, then –
Parling, Kjellin, receiving treatment to 47 individual, 1-month FU
& Gustafsson at a specialized ED 12 group
center in Sweden TAU – – – –
2016 Hancock et al. Children and 193 58 11.2 2.76 78 ACT Psychologists 10 1/week 90
adolescents who and graduate
met DSM-IV students
criteria for at least CBT Psychologists 10 1/week 90
one anxiety and graduate
disorder students
Waitlist NA NA NA NA
2016 Lang et al. Adult veterans with 160 20 34.2 8 75 ACT Psychologists 12 1/week 60
DSM-IV diagnosis and social

29
of at least one workers
anxiety or Present-centered therapy Psychologists 12 1/week 60
depressive disorder and social
workers
2016 Kanstrup et al. Adolescents with 30 80 16 1.6 – ACT Psychologist 18 – 45
chronic pain ACT Psychologist 18 – 120
2016 Parling, Adults with a 43 97.67 25.7 7.15 – ACT + TAU Psychologist and 19 – 60
Cernvall, diagnosis of AN or graduate
Ramklint, EDNOS who had students
Holmgren, & received 9–12 TAU – – – –
Ghaderi weeks of daycare at
a specialist eating
disorder unit
2016 Yazdanbakhsh, Adult women with 30 100 – – – ACT – 8 1/week 90
Kaboudi, multiple sclerosis Waitlist NA NA NA NA
Roghanchi,
Dehghan, &
Nooripour
2017 Clarke, Poulis, Adults diagnosed 31 70.97 66.5 9 96.77 ACT Ph.D. 6 1/week 90
Moreton, with knee or hip TAU – – – –
Walsh, & osteoarthritis
Lincoln
Behaviour Research and Therapy 104 (2018) 14–33
 2017 Gumley et al. Adults with 29 34.5 46.5 9 93.1 ACT – 15.4 mean, – –
schizophrenia and 5.9 SD
major depression TAU – – – –
2017 Herbert et al. Veterans with 128 17.8 52 13.3 47 In-person ACT Therapists with 8 1/week 60
C.W. Ong et al.

diagnosis of at least Master's-

chronic, level psychology
nonterminal pain training
condition Videoteleconference ACT Therapists with 8 1/week 60
at least Master's-
level psychology
training
2017 Lytsy, Carlsson, Women who were 327 100 48.5 8.3 – ACT – – – 60
& Anderzén on sick leave or Individualized – – 1/week –
time-restricted rehabilitation plan
disability pension Control (no intervention) NA NA NA NA
due to mental
illness or a pain
syndrome
2017 Palmeir, Pinto- Adult women with 73 100 41.97 8.79 – ACT + TAU Psychologist and 10 1/week, then 150
Gouveia, & BMI ≥ 25 graduate student 1/2 weeks
Cunha receiving 42.73 8.36 TAU – – – –
nutritional
treatment for
weight loss
2017 Shawyer et al. Adults with 96 38.5 36.1 9.1 – ACT Psychologists 8 1/1 to 2 50

30
schizophrenia or weeks
schizoaffective TAU Psychologists 8 1/1 to 2 50
disorder weeks
2017 Shorey et al. Adults in a 117 25.6 41.27 10.68 92.2 TAU + mindfulness and Graduate 8 2/week 90
residential 34.4 42.47 10.54 87.6 acceptance group student
substance use 15.1 39.83 10.73 96.2 TAU Primarily Variable 7/week Variable
treatment program licensed
chemical
dependency
counselors

Note. AN = anorexia nervosa; ACT = acceptance and commitment therapy; BMI = body mass index; BPD = borderline personality disorder; CBT = cognitive behavioral therapy; CT = cognitive therapy; DCR = Diagnostic Criteria for Research;
DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; DSM-IV-TR = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision; EDNOS = eating disorder, not otherwise specified; GAD = generalized anxiety
disorder; ICD-10 = International Statistical Classification of Diseases and Related Health Problems, 10th revision; MS = multiple sclerosis; MTAU = medication treatment as usual; OCD = obsessive-compulsive disorder; SSRI = selective serotonin
reuptake inhibitor; TAU = treatment as usual; TTM = trichotillomania.
Behaviour Research and Therapy 104 (2018) 14–33
C.W. Ong et al.
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