View source for Acceptance and commitment therapy

{{Short description|Form of cognitive behavioral therapy}}
{{Infobox medical intervention|name=Acceptance and commitment therapy|image=|caption=|ICD10=|ICD9=|MeshID=D064869|OPS301=|other_codes=|HCPCSlevel2=}}
{{Mindfulness|Psychology}}
'''Acceptance and commitment therapy''' ('''ACT''', typically pronounced as the word "act") is a form of [[psychotherapy]], as well as a branch of [[clinical behavior analysis]].<ref name="Plumb">{{cite journal |last1=Plumb |first1=Jennifer C. |last2=Stewart |first2=Ian |last3=Dahl |first3=Joanne |last4=Lundgren |first4=Tobias |date=Spring 2009 |title=In search of meaning: values in modern clinical behavior analysis |journal=[[The Behavior Analyst]] |volume=32 |issue=1 |pages=85–103 |pmid=22478515 |pmc=2686995 |doi=10.1007/BF03392177}}</ref> It is an [[empirical]]ly-based [[psychological]] [[intervention (counseling)|intervention]] that uses [[acceptance]] and [[mindfulness]] strategies<ref name="act">{{cite web |last=Hayes |first=Steven C. |author-link=Steven C. Hayes |title=Acceptance & Commitment Therapy (ACT) |publisher=ContextualPsychology.org |url= http://www.contextualpsychology.org/act}}</ref> along with commitment and behavior-change strategies to increase [[psychological flexibility]]. 

This approach was first called ''comprehensive distancing''.<ref name="baojournal.com" /> [[Steven C. Hayes]] developed it around 1982 to integrate features of cognitive therapy and behavior analysis, especially behavior analytic data on the often negative effects of verbal rules and how they might be ameliorated.<ref>{{cite book |last1=Waltz |first1=Thomas J. |last2=Hayes |first2=Steven C. |chapter=Acceptance and Commitment Therapy |title=Cognitive and Behavioral Theories in Clinical Practice |editor1-last=Kazantzis |editor1-first=Nikolaos |editor2-last=Reinecke |editor2-first=Mark A. |editor3-last=Freeman |editor3-first=Arthur |location=New York |publisher=[[Guilford Press]] |year=2010 |isbn=978-1-60623-342-9 |oclc=317927326 |pages=[https://books.google.com/books?id=y4SOyU12iTYC&pg=PA155 155–156]}}</ref> 

ACT protocols vary with the target behavior and the setting. For example, in behavioral health, a [[Brief psychotherapy|brief]] version of ACT is ''focused acceptance and commitment therapy'' (FACT).<ref>{{cite web |title=Focused Acceptance and Commitment Therapy (FACT): Mastering The Basics |url=https://contextualscience.org/wc12_strosahl_robinson_gustavsson |publisher=[[Association for Contextual Behavioral Science]] |website=contextualscience.org |archive-url=https://web.archive.org/web/20160407201937/https://contextualscience.org/wc12_strosahl_robinson_gustavsson |archive-date=2016-04-07 |access-date=2016-04-07}}</ref>

The goal of ACT is not to eliminate difficult feelings but to be present with what life brings and to "move toward valued behavior".<ref name=Hayes2012/>{{rp|240}} Acceptance and commitment therapy invites people to open up to unpleasant feelings, not to overreact to them, and not to avoid situations that cause them.

Its therapeutic effect aims to be a positive spiral, in which more understanding of one's emotions leads to a better understanding of the truth.<ref>{{cite web |last= Shpancer |first= Noam |date= September 8, 2010 |title= Emotional Acceptance: Why Feeling Bad is Good |website= [[Psychology Today]] blogs |url= https://www.psychologytoday.com/us/blog/insight-therapy/201009/emotional-acceptance-why-feeling-bad-is-good}}</ref> In ACT, "truth" is measured through the concept of "workability", or what works to take another step toward what matters (e.g., values, meaning).

==Technique==
===Basics===
ACT is developed within a [[pragmatism|pragmatic]] philosophy, [[functional contextualism]]. ACT is based on [[relational frame theory]] (RFT), a comprehensive theory of language and cognition that is derived from [[behavior analysis]]. Both ACT and RFT are based on [[B. F. Skinner]]'s philosophy of [[radical behaviorism]].<ref>{{Cite journal|last1=Kohlenberg|first1=Robert|last2=Hayes|first2=Steven|last3=Tsai|first3=Mavis|year=1993|title=Radical behavioral psychotherapy: two contemporary examples|journal=[[Clinical Psychology Review]]|volume=13|issue=6|pages=579–592|doi=10.1016/0272-7358(93)90047-p|citeseerx=10.1.1.542.4819}}</ref>

ACT differs from some kinds of [[cognitive behavioral therapy]] (CBT) in that, rather than try to teach people to control their thoughts, feelings, sensations, memories, and other private events, ACT teaches them to "just notice", accept, and embrace their private events, especially previously unwanted ones. ACT helps the individual get in contact with a [[transcendence (philosophy)|transcendent]] sense of self, "[[self-as-context]]"—the one who is always there observing and experiencing and yet distinct from one's thoughts, feelings, sensations, and memories. ACT tries to help the individual clarify values and then use them as the basis for action, bringing more vitality and meaning to life in the process, while increasing [[psychological flexibility]].<ref name="baojournal.com">{{cite journal|last1=Zettle|first1=Robert D.|year=2005|title=The evolution of a contextual approach to therapy: from comprehensive distancing to ACT|journal=International Journal of Behavioral Consultation and Therapy|volume=1|issue=2|pages=77–89|doi=10.1037/h0100736|doi-access=free}}</ref>

While Western psychology has typically operated under the "healthy normality" assumption, which states that humans naturally are psychologically healthy, ACT assumes that the psychological processes of a normal human mind are often destructive.<ref name="Harris"/> The core conception of ACT is that psychological suffering is usually caused by [[experiential avoidance]], cognitive entanglement, and resulting psychological rigidity that leads to a failure to take needed behavioral steps in accord with core values.<ref>{{Cite journal |last1=Cookson |first1=Camilla |last2=Luzon |first2=Olga |last3=Newland |first3=John |last4=Kingston |first4=Jessica |date=September 2020 |title=Examining the role of cognitive fusion and experiential avoidance in predicting anxiety and depression |url=https://pubmed.ncbi.nlm.nih.gov/30994261/ |journal=Psychology and Psychotherapy |volume=93 |issue=3 |pages=456–473 |doi=10.1111/papt.12233 |issn=2044-8341 |pmid=30994261|s2cid=119535460 }}</ref> As a simple way to summarize the model, ACT views the core of many problems to be due to the concepts represented in the acronym, FEAR:<ref name="Powers2009">{{Cite journal|last1=Powers|first1=Mark B.|last2=Zum Vörde Sive Vörding|first2=Maarten B.|last3=Emmelkamp|first3=Paul M. G.|date=2009|title=Acceptance and commitment therapy: a meta-analytic review|journal=[[Psychotherapy and Psychosomatics]]|volume=78|issue=2|pages=73–80|doi=10.1159/000190790|pmid=19142046|citeseerx=10.1.1.476.7775|s2cid=5916829|issn=0033-3190}}</ref>
* '''F'''usion with your thoughts
* '''E'''valuation of experience
* '''A'''voidance of your experience
* '''R'''eason-giving for your behavior

And the healthy alternative is to ACT:
* '''A'''ccept your thoughts and emotions
* '''C'''hoose a valued direction
* '''T'''ake action

===Core principles===
ACT commonly employs six core principles to help clients develop [[psychological flexibility]]:<ref name="Harris">{{cite journal |last=Harris |first=Russ |date=August 2006 |title=Embracing your demons: an overview of Acceptance and Commitment Therapy |journal=Psychotherapy in Australia |volume=12 |issue=4 |pages=2–8 |url=http://actmindfully.com.au/upimages/Dr_Russ_Harris_-_A_Non-technical_Overview_of_ACT.pdf}}</ref>
# Cognitive defusion: Learning methods to reduce the tendency to [[Reification (fallacy)|reify]] thoughts, images, emotions, and memories.
# Acceptance: Allowing unwanted private experiences (thoughts, feelings and urges) to come and go without struggling with them.
# Contact with the present moment: Awareness of the here and now, experienced with openness, interest, and receptiveness. (e.g., mindfulness)
# The observing self: Accessing a transcendent sense of self, a continuity of consciousness which is unchanging.
# Values: Discovering what is most important to oneself.<ref>{{cite journal |first1=Hank |last1=Robb |year=2007 |title=Values as Leading Principles in Acceptance and Commitment Therapy |journal=International Journal of Behavioral Consultation and Therapy |volume=3 |issue=1 |pages=118–23 |url=http://www.eric.ed.gov/ERICWebPortal/search/detailmini.jsp?_nfpb=true&_&ERICExtSearch_SearchValue_0=EJ801192&ERICExtSearch_SearchType_0=no&accno=EJ801192 |doi=10.1037/h0100170|url-access=subscription |doi-access=free }}</ref>
# Committed action: Setting goals according to values and carrying them out responsibly, in the service of a meaningful life.

Correlational evidence has found that absence of psychological flexibility predicts many forms of psychopathology. A 2005 [[meta-analysis]] showed that the six ACT principles, on average, account for 16–29% of the variance in psychopathology (general mental health, depression, anxiety) at baseline, depending on the measure, using correlational methods.<ref name=hayes06 />{{rp|12–13}} A 2012 meta-analysis of 68 laboratory-based studies on ACT components has also provided support for the link between psychological flexibility concepts and specific components.<ref>{{cite journal |doi=10.1016/j.beth.2012.05.003 |title=The Impact of Treatment Components Suggested by the Psychological Flexibility Model: A Meta-Analysis of Laboratory-Based Component Studies |year=2012 |last1=Levin |first1=Michael E. |last2=Hildebrandt |first2=Mikaela J. |last3=Lillis |first3=Jason |last4=Hayes |first4=Steven C. |journal=[[Behavior Therapy (journal)|Behavior Therapy]] |volume=43 |issue=4 |pages=741–56 |pmid=23046777}}</ref>

==Research==
The website of the [[Association for Contextual Behavioral Science]] states that there were over 1,300 [[randomized controlled trial]]s (RCTs) of ACT,<ref name="ACBS RCTs">{{cite web |title=ACT Randomized Controlled Trials (1986 to present) |url=https://contextualscience.org/act_randomized_controlled_trials_1986_to_present |access-date=2024-05-28 |website=contextualscience.org |publisher=[[Association for Contextual Behavioral Science]]}}</ref> over 550 meta-analyses/systematic reviews, and 88 [[Mediation (statistics)|mediational]] studies of the ACT literature as of January 2025.<ref name="ACBS evidence">{{cite web |url=https://contextualscience.org/state_of_the_act_evidence |title=State of the ACT Evidence |website=contextualscience.org |publisher=[[Association for Contextual Behavioral Science]] |access-date=2025-02-13}}</ref>

Organizations that have stated that acceptance and commitment therapy is empirically supported in certain areas or as a whole according to their standards include (as of March 2022):<ref name="ACBS evidence" />
* Society of Clinical Psychology (American Psychological Association/[[American Psychological Association|APA]] Division 12)
*[[World Health Organization]]
* UK [[National Institute for Health and Care Excellence]]
* [[Australian Psychological Society]]
* Netherlands Institute of Psychologists: Sections of Neuropsychology and Rehabilitation
* Netherlands National Institute for Public Health and the Environment (RIVM)
* Sweden Association of Physiotherapists
* [[Substance Abuse and Mental Health Services Administration|SAMHSA]]'s National Registry of Evidence-based Programs and Practices
* California Evidence-Based Clearinghouse for Child Welfare
* [[U.S. Department of Veterans Affairs]]/[[Department of Defense (United States)|Department of Defense]]
* US Department of Justice - Office of Justice Programs
* Washington State Institute for Public Policy
* American Headache Society

===History===
In 2006, only about 30 randomized clinical trials and controlled time series evaluating ACT were known,<ref name=hayes06>{{cite journal |doi=10.1016/j.brat.2005.06.006 |title=Acceptance and Commitment Therapy: Model, processes and outcomes |year=2006 |last1=Hayes |first1=Steven C. |last2=Luoma |first2=Jason B. |last3=Bond |first3=Frank W. |last4=Masuda |first4=Akihiko |last5=Lillis |first5=Jason |journal=[[Behaviour Research and Therapy]] |volume=44 |pages=1–25 |pmid=16300724 |issue=1|url=https://scholarworks.gsu.edu/cgi/viewcontent.cgi?article=1085&context=psych_facpub|url-access=subscription }}</ref> in 2011 the number had doubled to more than 60 ACT randomized controlled trials,<ref>{{cite journal |last=Ruiz |first=F. J. |year=2010 |title=A review of Acceptance and Commitment Therapy (ACT) empirical evidence: Correlational, experimental psychopathology, component and outcome studies |journal=International Journal of Psychology and Psychological Therapy |volume=10 |issue=1 |pages=125–62 |url=http://www.ijpsy.com/volumen10/num1/256.html}}</ref> and in 2023 there were more than 1,000 randomized controlled trials  of ACT worldwide.<ref name="ACBS RCTs" /> A 2008 meta-analysis concluded that the evidence was still too limited for ACT to be considered a supported treatment.<ref name="Ost2008">{{cite journal |doi=10.1016/j.brat.2007.12.005 |title=Efficacy of the third wave of behavioral therapies: A systematic review and meta-analysis |year=2008 |last=Öst |first=Lars-Göran |journal=[[Behaviour Research and Therapy]] |volume=46 |issue=3 |pages=296–321 |pmid=18258216}}</ref> A 2009 meta-analysis found that ACT was more effective than placebo and "treatment as usual" for most problems.<ref name="Powers2009" /> A 2012 meta-analysis was more positive and reported that ACT outperformed CBT, except for treating depression and anxiety.<ref name="ijpsy2012" /> A 2015 review found that ACT was better than placebo and typical treatment for [[anxiety disorders]], [[Depression (mood)|depression]], and [[addiction]].<ref name="davis2015"/> Its effectiveness was similar to traditional treatments like [[cognitive behavioral therapy]] (CBT).<ref name="davis2015">{{cite journal |last1=A-Tjak |first1=Jacqueline G. L. |last2=Davis |first2=Michelle L. |last3=Morina |first3=Nexhmedin |last4=Powers |first4=Mark B. |last5=Smits |first5=Jasper A. J. |last6=Emmelkamp |first6=Paul M. G. |date=2015 |title=A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems |journal=[[Psychotherapy and Psychosomatics]] |volume=84 |issue=1 |pages=30–36 |pmid=25547522 |doi=10.1159/000365764 |s2cid=215537860 |url=https://pure.uva.nl/ws/files/2436404/157849_429302_preprint.pdf}}</ref> The authors also noted that research methodologies had improved since the studies described in the 2008 meta-analysis.<ref name="davis2015" />

In 2020, a review of meta-analyses examined 20 meta-analyses that included 133 studies and 12,477 participants. The authors concluded ACT is efficacious for all conditions examined, including anxiety, depression, substance use, pain, and [[Transdiagnostic process|transdiagnostic]] groups. Results also showed that ACT was generally superior to inactive controls, treatment as usual, and most active intervention conditions.<ref>{{cite journal |last1=Gloster |first1=Andrew T. |last2=Walder |first2=Noemi |last3=Levin |first3=Michael E. |last4=Twohig |first4=Michael P. |last5=Karekla |first5=Maria |date=2020 |title=The Empirical Status of Acceptance and Commitment Therapy: A Review of Meta-analyses|journal=Journal of Contextual Behavioral Science |volume=18 |pages=181–192 |doi=10.1016/j.jcbs.2020.09.009 |s2cid=224928250 |doi-access=free |bibcode=2020JCBS...18..181G }}</ref>

In 2020–2021, after three RCTs of ACT by the World Health Organization (WHO), WHO released an ACT-based self-help course Self-Help Plus (SH+) for "groups of up to 30 people who have lived through or are living through adversity".<ref name="WHO">{{cite web |url=https://www.who.int/news/item/11-10-2021-new-stress-management-course-for-people-living-with-adversity |title=New stress management course for people living with adversity |website=www.who.int |publisher=World Health Organization |date=11 October 2021 |access-date=2022-03-30}} See also the course materials: {{cite web |url=https://www.who.int/publications-detail/9789240003927 |title=Doing What Matters in Times of Stress |website=www.who.int |publisher=World Health Organization |access-date=2022-03-30}}</ref> As of July 2023, there are six RCTs of Self-Help Plus.<ref>{{cite journal |last1=Mediavilla |first1=Roberto |date=2023 |title=Effectiveness of a mental health stepped-care programme for healthcare workers with psychological distress in crisis settings: a multicentre randomised controlled trial |journal=[[BMJ Mental Health (journal)|BMJ Mental Health]] |volume=26 |issue=1 |pages=e300697|doi=10.1136/bmjment-2023-300697 |pmid=37263708 |s2cid=259024864 |doi-access=free |pmc=10254812 }}</ref>

In 2022, a systematic review of meta-analyses about interventions for depressive symptoms in people living with chronic pain concluded "Acceptance and commitment therapy for general chronic pain, and fluoxetine and web-based psychotherapy for fibromyalgia showed the most robust effects and can be prioritized for implementation in clinical practice".<ref>{{cite journal |last1=Cheng |first1=Darren K. |last2=Lai |first2=Ka Sing Paris |last3=Pico-Espinosa |first3=Oscar Javier |last4=Rice |first4=Danielle B. |last5=Chung |first5=Chadwick |last6=Modarresi |first6=Golale |last7=Sud |first7=Abhimanyu |date=2022 |title=Interventions for depressive symptoms in people living with chronic pain: a systematic review of meta-analyses |journal=[[Pain Medicine (journal)|Pain Medicine]] |volume=23 |issue=5 |pages=934–954 |doi=10.1093/pm/pnab248 |pmid=34373915 |pmc=9071227}}</ref>

== Professional organizations ==
The [[Association for Contextual Behavioral Science]] is committed to research and development in the area of ACT, RFT, and contextual behavioral science more generally. As of 2023 it had over 8,000 members worldwide, about half outside of the United States. It holds annual "world conference" meetings each summer, with the location alternating between North America, Europe, and South America.<ref>{{cite web|title=Conferences|url=http://contextualscience.org/conferences|access-date=2017-11-07|publisher=[[Association for Contextual Behavioral Science]]}}</ref>

The [[Association for Behavior Analysis]] International (ABAI) has a special interest group for practitioner issues, behavioral counseling, and clinical behavior analysis ABA:I.<ref>{{Cite web |title=Special Interest Groups - Association for Behavior Analysis International |url=https://www.abainternational.org/constituents/special-interests/special-interest-groups.aspx |access-date=2022-03-09 |website=www.abainternational.org}}</ref> ABAI has larger special interest groups for [[autism]] and [[behavioral medicine]]. ABAI serves as the core intellectual home for behavior analysts.<ref>{{cite journal|last1=Twyman|first1=J.S.|year=2007|title=A new era of science and practice in behavior analysis|journal=Association for Behavior Analysis International: Newsletter|volume=30|issue=3|pages=1–4}}</ref><ref>{{cite journal|last1=Hassert|first1=Derrick L.|last2=Kelly|first2=Amanda N.|last3=Pritchard|first3=Joshua K.|last4=Cautilli|first4=Joseph D.|year=2008|title=The Licensing of Behavior Analysts: Protecting the Profession and the Public|url=http://www.eric.ed.gov/ERICWebPortal/search/detailmini.jsp?_nfpb=true&_&ERICExtSearch_SearchValue_0=EJ829086&ERICExtSearch_SearchType_0=no&accno=EJ829086|journal=Journal of Early and Intensive Behavior Intervention|volume=5|issue=2|pages=8–19|doi=10.1037/h0100415|url-access=subscription|doi-access=free}}</ref> ABAI sponsors three conferences/year—one multi-track in the U.S., one specific to autism and one international.

The [[Association for Behavioral and Cognitive Therapies]] (ABCT) also has an interest group in [[behavior analysis]], which focuses on clinical behavior analysis. ACT work is commonly presented at ABCT and other mainstream CBT organizations.

The [[British Association for Behavioural and Cognitive Psychotherapies]] (BABCP) has a large special interest group in ACT, with over 1,200 members.

Doctoral-level behavior analysts who are psychologists belong to the [[American Psychological Association]]'s (APA) Division 25—[[Behavior analysis]].<ref>{{cite web|title=About the Behavior Analysis Division|url=http://www.apadivisions.org/division-25/about/|access-date=2018-08-07|website=apadivisions.org|publisher=[[American Psychological Association]]}}</ref> ACT has been called a "commonly used treatment with empirical support" within the APA-recognized specialty of behavioral and cognitive psychology.<ref>{{cite web|title=Behavioral and Cognitive Psychology Public Description|url=https://www.apa.org/ed/graduate/specialize/behav.aspx|access-date=2018-08-07|website=apa.org|publisher=[[American Psychological Association]]}}</ref>

== Similarities ==
{{See also|Cognitive behavioral therapy#Behavior and cognitive therapies merge – third wave CBT}}
ACT, [[dialectical behavior therapy]] (DBT), [[functional analytic psychotherapy]] (FAP), [[mindfulness-based cognitive therapy]] (MBCT) and other acceptance- and mindfulness-based approaches have been grouped by Steven Hayes under the name "the third wave of cognitive behavior therapy".<ref name="Ost2008" /><ref>{{cite book |first=Christopher R. |last=Martell |author2=Michael E. Addis|author3=Neil S. Jacobson |year=2001 |title=Depression in Context: Strategies for Guided Action |publisher=W. W. Norton |isbn=978-0-393-70350-4 |location=New York |page=197}}</ref> However, this classification has been criticized and not everyone agrees with it.<ref name=Hofmann2008a>{{cite journal |doi=10.1016/j.cpr.2007.09.003 |title=Acceptance and mindfulness-based therapy: New wave or old hat? |year=2008 |last1=Hofmann |first1=Stefan G. |last2=Asmundson |first2=Gordon J.G. |journal=[[Clinical Psychology Review]] |volume=28 |pages=1–16 |pmid=17904260 |issue=1}}</ref><ref name=DozoisBeck2011/> For example, David Dozois and [[Aaron T. Beck]] argued that there is no "new wave" and that there are a variety of extensions of cognitive therapy; for example, [[Jeffrey Young (psychologist)|Jeffrey Young]]'s [[schema therapy]] came after Beck's cognitive therapy but Young did not name his innovations "the third wave" or "the third generation" of cognitive behavior therapy.<ref name=DozoisBeck2011>{{cite book |last1=Dozois |first1=David J. A. |last2=Beck |first2=Aaron T. |author-link2=Aaron T. Beck |date=2011 |chapter=Cognitive therapy |editor1-last=Herbert |editor1-first=James D. |editor2-link=James D. Herbert (psychologist) |editor2-last=Forman |editor2-first=Evan M. |title=Acceptance and mindfulness in cognitive behavior therapy: understanding and applying the new therapies |location=Hoboken, NJ |publisher=[[John Wiley & Sons]] |pages=26–56 (37) |isbn=9780470474419 |oclc=612189071 |doi=10.1002/9781118001851.ch2 |quote=Though mindfulness- and acceptance-based strategies have not been emphasized in cognitive therapy relative to cognitive change interventions, their general approaches are not inconsistent with the cognitive model, and the approaches are, in many respects, more similar than distinct&nbsp;... Congruent with this argument, we view these approaches as extensions or complementary components of cognitive therapy and not a "third wave" per se (see Hofmann, 2008a; Hofmann & Asmundson, 2008).}}</ref>

According to Hayes' classification, the first wave, [[behaviour therapy]], commenced in the 1920s based on Pavlov's [[Classical conditioning|classical (respondent) conditioning]] and [[operant conditioning]] that was correlated to reinforcing consequences. The second wave emerged in the 1970s and included cognition in the form of irrational beliefs, dysfunctional attitudes or depressogenic attributions.<ref name="Leahy, R. L. 2004">{{cite book |editor-last=Leahy |editor-first=Robert L. |editor-link=Robert L. Leahy |date=2004 |title=Contemporary cognitive therapy: theory, research, and practice |location=New York |publisher=[[Guilford Press]] |isbn=159385062X |oclc=55228722}}</ref>{{Page needed|date=August 2021}} In the late 1980s empirical limitations and philosophical misgivings of the second wave gave rise to Steven Hayes' ACT theory which modified the focus of abnormal behaviour away from the content or form towards the context in which it occurs.<ref name="Leahy, R. L. 2004" />{{Page needed|date=August 2021}} People's rigid ideas about themselves, their lack of focus on what is important in their life, and their struggle to change sensations, feelings or thoughts that are troublesome only serve to create greater distress.<ref>{{cite book |last1=Hayes |first1=Steven C. |author-link1=Steven C. Hayes |last2=Smith |first2=Spencer Xavier |date=2005 |title=Get out of your mind & into your life: the new acceptance & commitment therapy |series=A New Harbinger self-help workbook |location=Oakland, CA |publisher=[[New Harbinger Publications]] |isbn=9781572244252 |oclc=61229775}}</ref>

[[Steven C. Hayes]] described the third wave in his [[Association for Behavioral and Cognitive Therapies|ABCT]] President Address as follows:

{{blockquote|Grounded in an empirical, principle-focused approach, the third wave of behavioral and cognitive therapy is particularly sensitive to the context and functions of psychological phenomena, not just their form, and thus tends to emphasize contextual and experiential change strategies in addition to more direct and didactic ones. These treatments tend to seek the construction of broad, flexible and effective repertoires over an eliminative approach to narrowly defined problems, and to emphasize the relevance of the issues they examine for clinicians as well as clients. The third wave reformulates and synthesizes previous generations of behavioral and cognitive therapy and carries them forward into questions, issues, and domains previously addressed primarily by other traditions, in hopes of improving both understanding and outcomes.<ref>{{cite journal |last=Hayes |first=Steven C. |date=September 2004 |title=Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies |journal=[[Behavior Therapy (journal)|Behavior Therapy]] |volume=35 |issue=4 |pages=639–665 (658) |doi=10.1016/S0005-7894(04)80013-3 |url=https://contextualscience.org/files/318%20ACT%20RFT%20and%20the%20Third%20Wave%20BT%202004.pdf}}</ref>}}

ACT has also been adapted to create a non-therapy version of the same processes called ''acceptance and commitment training''. This training process, oriented towards the development of mindfulness, acceptance, and valued skills in non-clinical settings such as businesses or schools, has also been investigated in a handful of research studies with good preliminary results.<ref>{{cite book |editor1-last=Hayes |editor1-first=Steven C. |editor2-last=Bond |editor2-first=Frank W. |editor3-last=Barnes-Holmes |editor3-first=Dermot |editor4-last=Austin |editor4-first=John |date=2006 |title=Acceptance and mindfulness at work: applying acceptance and commitment therapy and relational frame theory to organizational behavior management |location=New York |publisher=[[Haworth Press]] |isbn=0789034786 |oclc=70775707 |doi=10.4324/9781315808383}}</ref>{{Page needed|date=November 2012}}

The emphasis of ACT on ongoing present moment [[awareness]], valued directions and committed action is similar to other psychotherapeutic approaches that, unlike ACT, are not as focused on outcome research or consciously linked to a basic behavioral science program, including approaches such as [[Gestalt therapy]], [[Morita therapy]], and others.<ref>{{cite journal |last=Dougher |first=Michael J. |date=Fall 2002 |title=This is not B. F. Skinner's behavior analysis: a review of Hayes, Strosahl, And Wilson's ''Acceptance and Commitment Therapy'' |journal=[[Journal of Applied Behavior Analysis]] |volume=35 |issue=3 |pages=323–336 (323) |doi=10.1901/jaba.2002.35-323 |pmc=1284396 |quote=Instead of the familiar litany of behavior analytic-terms and concepts, this book is replete with terms and themes that are more commonly associated with such philosophical and therapeutic traditions as existentialism, humanism, Zen Buddhism, Gestalt, and other experiential-based therapies.}}</ref><ref name=Hofmann2008b>{{cite journal |last=Hofmann |first=Stefan G. |date=December 2008 |title=Acceptance and commitment therapy: new wave or Morita therapy? |journal=[[Clinical Psychology: Science and Practice]] |volume=15 |issue=4 |pages=280–285 (280–281) |doi=10.1111/j.1468-2850.2008.00138.x |quote=the criticism offered by ACT against CBT is based on a misrepresentation of the empirical evidence. Moreover, the strategies of ACT are not specific to the theory and philosophy underlying ACT. There are considerable similarities between ACT and Eastern holistic approaches, such as Morita therapy, which was developed 80 years ago.&nbsp;... According to Hayes and colleagues, the principal goal of ACT is to "treat emotional avoidance, excessive literal response to cognitive content, and the inability to make and keep commitments to behavior change" (Kohlenberg, Hayes, & Tsai, 1995, p. 584). This appears to be consistent with many old humanistic therapies and holistic approaches, such as Gestalt therapy (e.g., Perls, Hefferline, & Goodman, 1951). Particularly striking is the similarity between ACT and Morita therapy (Morita, 1928; translated in English in 1998).}}</ref><ref>{{cite AV media |date=24 July 2017 |title=Steven C. Hayes – Interview about ACT |medium=Video |url=https://www.youtube.com/watch?v=xZHCpazRg0o  |archive-url=https://ghostarchive.org/varchive/youtube/20211221/xZHCpazRg0o |archive-date=2021-12-21 |url-status=live|time=18:21 |access-date=5 August 2021 |location=Los Mochis, Sinaloa, Mexico |publisher=Centro Integral de Psicología |via=[[YouTube]] |quote=I would have to say a lot of what's in ACT is in Gestalt, is in Est, is in mindfulness-based traditions, but I'm not embarrassed by that; I think it's to be expected that things like the wisdom traditions, spiritual traditions, human potential/growth traditions, Gestalt, these things were there because very very creative people put them there.&nbsp;... The history of psychology would be different if people realized that there was a lot of overlap in the early days between these things that then get put behind walls and students start fighting about and saying, oh, this is very different than that.}}{{cbignore}}</ref> Hayes and colleagues themselves stated in their book that introduced ACT that "many or even most of the techniques in ACT have been borrowed from elsewhere—from the human potential movement, Eastern traditions, behavior therapy, mystical traditions, and the like".<ref>{{cite book |last1=Hayes |first1=Steven C. |last2=Strosahl |first2=Kirk |last3=Wilson |first3=Kelly G. |date=1999 |title=Acceptance and commitment therapy: an experiential approach to behavior change |edition=1st |location=New York |publisher=[[Guilford Press]] |page=15 |isbn=1572304812 |oclc=41712470}}</ref>

Wilson, Hayes & Byrd explored at length the compatibilities between ACT and the [[12-step]] treatment of addictions and argued that, unlike most other psychotherapies, both approaches can be implicitly or explicitly integrated due to their broad commonalities.<ref name=Wilson2000/> Both approaches endorse acceptance as an alternative to unproductive control. ACT emphasizes the hopelessness of relying on ineffectual strategies to control private experience, similarly the 12-step approach emphasizes the acceptance of powerlessness over addiction. Both approaches encourage a broad life-reorientation, rather than a narrow focus on the elimination of substance use, and both place great value on the long-term project of building of a meaningful life aligned with the clients' values. ACT and 12-step both encourage the pragmatic utility of cultivating a transcendent sense of self ([[higher power]]) within an unconventional, individualized spirituality. Finally they both openly accept the paradox that acceptance is a necessary condition for change and both encourage a playful awareness of the limitations of human thinking.<ref name=Wilson2000>{{cite journal |title=Exploring Compatibilities Between Acceptance and Commitment Therapy and 12-Step Treatment for Substance Abuse|doi=10.1023/A:1007835106007 |year=2000 |last1=Wilson |first1=Kelly G. |last2=Hayes |first2=Steven C. |last3=Byrd |first3=Michelle R. |journal=Journal of Rational-Emotive and Cognitive-Behavior Therapy |volume=18 |issue=4 |pages=209–234|s2cid=54635502}}</ref>

==Criticism==
{{See also|Psychotherapy#General critiques}}

The textbook ''Systems of Psychotherapy: A Transtheoretical Analysis'' includes various criticisms of third-wave behaviour therapy, including ACT, from the perspectives of other systems of psychotherapy, including the complaint that third-wave therapies "display an annoying tendency to gather effective methods from other traditions and label them as their own".<ref>{{cite book |last1=Prochaska |first1=James O. |author-link1=James O. Prochaska |last2=Norcross |first2=John C. |author-link2=John C. Norcross |date=2018 |title=Systems of psychotherapy: a transtheoretical analysis |edition=9th |location=New York |publisher=[[Oxford University Press]] |isbn=9780190880415 |oclc=1015276003 |pages=[https://books.google.com/books?id=4D9FDwAAQBAJ&pg=PA283 283–285]}}</ref>

===Evidence-based practice===
In a 2012 blog post, psychologist [[James C. Coyne]] criticized the process and studies initially used by the APA to favorably evaluate ACT for the treatment of [[psychosis]] in its labeling system for [[evidence-based medicine]]. In particular, it relied on only one full randomized trial, supplemented by a pilot study and a [[feasibility study]], despite the criteria for "strong evidence" requiring a treatment to be supported by many such trials.<ref>{{cite web |title=Research-Supported Psychological Treatments {{!}} Society of Clinical Psychology |url=https://div12.org/psychological-treatments/ |access-date=29 March 2024 |date=11 July 2014}}</ref><ref name="Coyne2012"/> The main study used (Bach and Hayes, 2002) was alleged not to have clearly specified its hypothesis—that ACT reduces rehospitalization—in advance of the conducted analysis: a practice in which researchers retrospectively [[cherry-pick]] the metric showing the largest claim-supporting change post-treatment.<ref name="Coyne2012">{{cite web|last=Coyne|first=James C.|author-link=James C. Coyne|date=22 October 2012|title=Troubles in the branding of psychotherapies as 'evidence supported'|url=http://blogs.plos.org/mindthebrain/2012/10/22/troubles-in-the-branding-of-psychotherapies-as-evidence-supported/|archive-url=https://web.archive.org/web/20160304014203/http://blogs.plos.org/mindthebrain/2012/10/22/troubles-in-the-branding-of-psychotherapies-as-evidence-supported/|archive-date=4 March 2016|access-date=4 May 2016|website=plos.org|publisher=[[PLOS]]}}</ref> In 2016, this and other critiques were cited by [[William O'Donohue]] and co-authors in a paper on ACT "weak and pseudo-tests", adding that while "no doubt there are studies of ACT that are quite good", they had examined three trials of ACT that were "weakened and thus made easier to pass", and they listed over 30 ways in which such trials were "weak or pseudo-tests".<ref name="ODonohue2016" /> Drawing on concepts from [[Karl Popper]]'s philosophy of science and Popper's critique of [[psychoanalysis]] as impossible to [[Falsifiability|falsify]], O'Donohue and colleagues advocated Popperian severe testing instead.<ref name="ODonohue2016">{{cite journal|last1=O'Donohue|first1=William|author-link1=William O'Donohue|last2=Snipes|first2=Cassandra|last3=Soto|first3=Cyndy|date=March 2016|title=The design, manufacture, and reporting of weak and pseudo-tests: the case of ACT|journal=Journal of Contemporary Psychotherapy|volume=46|issue=1|pages=37–40|doi=10.1007/s10879-015-9316-1|s2cid=33176278}}</ref>

===Excessive promotion over other therapies===
In 2013, psychologist Jonathan W. Kanter said that Hayes and colleagues "argue that empirical clinical psychology is hampered in its efforts to alleviate human suffering and present ''contextual behavioral science'' (CBS) to address the basic philosophical, theoretical and methodological shortcomings of the field. CBS represents a host of good ideas but at times the promise of CBS is obscured by excessive promotion of Acceptance and Commitment Therapy (ACT) and Relational Frame Theory (RFT) and demotion of earlier cognitive and behavior change techniques in the absence of clear logic and empirical support."<ref name="Kanter" /> Nevertheless, Kanter concluded that "the ideas of CBS, RFT, and ACT deserve serious consideration by the mainstream community and have great potential to shape a truly progressive clinical science to guide clinical practice".<ref name="Kanter">{{cite journal|last=Kanter|first=Jonathan W.|date=June 2013|title=The vision of a progressive clinical science to guide clinical practice|url=https://www.researchgate.net/publication/236275068|journal=[[Behavior Therapy (journal)|Behavior Therapy]]|volume=44|issue=2|pages=228–233|doi=10.1016/j.beth.2010.07.006|pmid=23611073}}</ref>

Authors of a 2013 paper comparing ACT to [[cognitive therapy]] (CT) concluded that "although preliminary research on ACT is promising, we suggest that its proponents need to be appropriately humble in their claims. In particular, like CT, ACT cannot yet make strong claims that its unique and theory-driven intervention components are active ingredients in its effects." The authors of the paper suggested that many of the assumptions of ACT and CT "are pre-analytical, and cannot be directly pitted against one another in experimental tests."<ref name="HerbertForman2013">{{cite journal|last1=Herbert|first1=James D.|last2=Forman|first2=Evan M.|date=June 2013|title=Caution: the differences between CT and ACT may be larger (and smaller) than they appear|journal=[[Behavior Therapy (journal)|Behavior Therapy]]|volume=44|issue=2|pages=218–223|doi=10.1016/j.beth.2009.09.005|pmid=23611071}}</ref>

In 2012, ACT appeared to be about as effective as standard CBT, with some meta-analyses showing small differences in favor of ACT and others not. For example, a meta-analysis published by Francisco Ruiz in 2012 looked at 16 studies comparing ACT to standard CBT.<ref name="ijpsy2012">{{cite journal|last=Ruiz Jiménez|first=Francisco José|date=2012|title=Acceptance and commitment therapy versus traditional cognitive behavioral therapy: A systematic review and meta-analysis of current empirical evidence|url=https://www.ijpsy.com/volumen12/num3/334/acceptance-andcommitment-therapy-versus-EN.pdf|journal=International Journal of Psychology and Psychological Therapy|volume=12|issue=3|pages=333–358}}</ref> ACT failed to separate from CBT on effect sizes for anxiety, however modest benefits were found with ACT compared to CBT for depression and quality of life. The author found a separation between ACT and CBT on the "primary outcome"—a heterogeneous class of 14 separate outcome measures aggregated into the effect size analysis. However, the study is limited by the highly heterogeneous nature of the outcome variables used in the analysis, which tends to increase the number needed to treat (NNT) to replicate the effect size reported. More limited measures, such as depression, anxiety, and quality of life, decrease the NNT, making the analysis more clinically relevant, and on these measures, ACT did not outperform CBT. A 2012 clinical trial by Forman et al. found that Beckian CBT obtained better results than ACT.<ref>{{cite journal |last1=Forman |first1=Evan M. |last2=Shaw |first2=Jena A. |last3=Goetter |first3=Elizabeth M. |last4=Herbert |first4=James D. |last5=Park |first5=Jennie A. |last6=Yuen |first6=Erica K. |date=December 2012 |title=Long-term follow-up of a randomized controlled trial comparing acceptance and commitment therapy and standard cognitive behavior therapy for anxiety and depression |journal=[[Behavior Therapy (journal)|Behavior Therapy]] |volume=43 |issue=4 |pages=801–811 |pmid=23046782 |doi=10.1016/j.beth.2012.04.004 |url=https://www.researchgate.net/publication/232224821}}</ref>

Several theoretical and empirical concerns have arisen in response to the ascendancy of ACT. One theoretical concern was that ACT's primary authors and the corresponding theories of human behavior, relational frame theory (RFT) and functional contextualism (FC), recommended their approach as the proverbial holy grail of psychological therapies.<ref>{{cite journal |last=Routier |first=Cédric P. |date=2007 |title=Relational frame theory (RFT) and acceptance and commitment therapy (ACT): Emperor's tailors or knights of the holy grail? |journal=Acta Comportamentalia |volume=15 |issue=3 |pages=45–69 |url=http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S0188-81452007000400004}}</ref> In 2012, in the preface to the second edition of ''Acceptance and Commitment Therapy'', the primary authors of ACT clarified that "ACT has not been created to undercut the traditions from which it came, nor does it claim to be a panacea."<ref name=Hayes2012>{{cite book|title=Acceptance and Commitment Therapy: The Process and Practice of Mindful Change|last1=Hayes|first1=Stephen C.|last2=Strosahl|first2=Kirk D.|last3=Wilson|first3=Kelly G.|date=2012|edition=2nd|publisher=[[Guilford Press]]|isbn=9781609189624|oclc=713181786}}</ref>{{rp|x}}

==See also==<!-- PLEASE RESPECT ALPHABETICAL ORDER -->
* [[Behavioral psychotherapy]]
* [[Contextualism]]
* {{section link|Decisional balance sheet|Four square tool}}
* [[Defence mechanism]]
* [[Humanistic psychology]]
* [[Positive psychology]]
* [[Solution-focused brief therapy]]

==References==
{{Reflist|30em}}

==External links==
* [https://contextualscience.org/ Contextualscience.org] – Home for the Association for Contextual Behavioral Science, a professional organization dedicated to ACT, RFT, and functional contextualism. Also helpful for training opportunities for professionals interested in ACT and RFT. Most ACT workshops worldwide are listed here.

{{Cognitive behavioral therapy}}
{{Psychotherapy}}

{{Authority control}}

[[Category:Behaviorism]]
[[Category:Cognitive behavioral therapy]]
[[Category:Mindfulness (psychology)]]
[[Category:Treatment of obsessive–compulsive disorder]]