Articles Comparing ACT to CBT

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ACT has raised controversy in various wings of CBT, e.g.,

  • Hofmann, S. G. (2008). Acceptance and Commitment Therapy: New Wave or Morita Therapy? Clinical Psychology, Science and Practice, 5, 280-285.
  • Öst, L. G. (2008). Efficacy of the third wave of behavioral therapies: A systematic review and meta-analysis. Behaviour Research and Therapy, 46(3), 296-321

The relation of ACT to CBT was discussed in the earliest ACT writings. e.g.,

  • Hayes, S. C. (1987). A contextual approach to therapeutic change. In Jacobson, N. (Ed.), Psychotherapists in clinical practice: Cognitive and behavioral perspectives (pp. 327 387). New York: Guilford.

And these more specific criticisms are gradually being answered, e.g.,

  • Hayes, S. C. (2008). Climbing our hills: A beginning conversation on the comparison of ACT and traditional CBT. Clinical Psychology: Science and Practice, 5, 286-295.
  • Hayes, S. C. (2008). Avoiding the mistakes of the past. The Behavior Therapist. 29, 150-153.
  • Hayes, S. C., Levin, M., Plumb, J., Boulanger, J., & Pistorello, J. (2013). Acceptance and Commitment Therapy and contextual behavioral science: Examining the progress of a distinctive model of behavioral and cognitive therapy. Behavior Therapy, 44, 180–198. doi: 10.1016/j.beth.2009.08.002 PMCID: PMC3635495
  • Atkins, P. W. B., Ciarrochi, J., Gaudiano, B. A., Bricker, J. B., Donald, J., Rovner, G., Smout, M., Livheim, F., Lundgren, T., Hayes, S. C. (2017). Departing from the essential features of a high quality systematic review of psychotherapy: A Response to Öst (2014) and recommendations for improvement. Behaviour Research and Therapy, 97, 259-272. Doi: 10.1016/j.brat.2017.05.016

In the 1980’s Steve Hayes and colleagues did a series of studies which found that cognitive and social learning methods did not work via processes described by these theories. e.g.,

  • Harmon, T. M., Nelson, R. O., & Hayes, S. C. (1980). Self monitoring of mood versus activity by depressed clients. Journal of Consulting and Clinical Psychology, 48, 30 38.
  • Hayes, S. C., & Nelson, R. O. (1983). Similar reactivity produced by external cues and self monitoring. Behavior Modification, 7, 183 196.
  • Hayes, S. C., Rincover, A., & Volosin, D. (1980). Variables influencing the acquisition and maintenance of aggressive behavior: Modeling versus sensory reinforcement. Journal of Abnormal Psychology, 89, 245 262.
  • Hayes, S. C., & Wolf, M. R. (1984). Cues, consequences, and therapeutic talk: Effect of social context and coping statements on pain. Behaviour Research and Therapy, 22, 385-392.
  • Jarrett, R. B., & Nelson, R. O. (1987). Mechanisms of change in cognitive therapy of depression. Behavior Therapy, 18, 227-241.
  • Nelson, R. O., Hayes, S. C., Spong, R. T., Jarrett, R. B., & McKnight, D. L. (1983). Self reinforcement: Appealing misnomer or effective mechanism? Behaviour Research and Therapy, 21, 557 566.
  • Zettle, R. D., & Hayes, S. C. (1982). Rule governed behavior: A potential theoretical framework for cognitive behavior therapy. In P. C. Kendall (Ed.), Advances in cognitive behavioral research and therapy (pp. 73 118). New York: Academic.
  • Zettle, R. D., & Hayes, S. C. (1983). Effect of social context on the impact of coping self statements. Psychological Reports, 52, 391 401.

    ACT followed a whole set of studies that showed that cognitive methods worked because of contextual factors

There is a growing set of empirical articles comparing ACT with traditional BT and CBT methods. Virtually all have shown differences at the level of process, and some in outcome.

  • Lappalainen, R., Lehtonen, T., Skarp, E., Taubert, E., Ojanen, M., & Hayes, S. C. (2007). The impact of CBT and ACT models using psychology trainee therapists: A preliminary controlled effectiveness trial. Behavior Modification, 31, 488-511.


    Randomized controlled study in which 14 student therapists treat one client each from an ACT model or a traditional CBT model for 6-8 sessions following a 2 session functional analysis. Participants with any normal outpatient problem were included, mostly anxiety and depression. At post and at the 6 month follow up ACT clients are more improved on the SCL-90 and several other measures. Greater acceptance for ACT patients; great self-confidence for CBT patients. Both correlated with outcomes, but when partial correlations are calculated, only acceptance still relates to outcome.


  • Forman, E. M., Herbert, J. D., Moitra, E., Yeomans, P. D., & Geller, P. A. (2007). A randomized controlled effectiveness trial of Acceptance and Commitment Therapy and Cognitive Therapy for anxiety and depression. Behavior Modification, 31(6), 772-799.


    101 heterogeneous outpatients reporting moderate to severe levels of anxiety or depression were randomly assigned either to traditional CT or to ACT. 23 junior therapists were used. Participants receiving CT and ACT evidenced large and equivalent improvements in depression, anxiety, functioning difficulties, quality of life, life satisfaction and clinician-rated functioning. “Observing” and “describing” one’s experiences mediated outcomes for those in the CT group relative to those in the ACT group, whereas “experiential avoidance,” “acting with awareness” and “acceptance” mediated outcomes for those in the ACT group.

  • Zettle, R. D. & Hayes, S. C. (1986). Dysfunctional control by client verbal behavior: The context of reason giving. The Analysis of Verbal Behavior, 4, 30 38.


    Small controlled trial. Shows that ACT is more effective that cognitive therapy for depression when presented in an individual format, and that it works by a different process.

  • Zettle, R. D., & Rains, J. C. (1989). Group cognitive and contextual therapies in treatment of depression. Journal of Clinical Psychology, 45, 438 445.


    Small controlled trial. Shows that ACT is as effective as cognitive therapy for depression when presented in a group format, and that it works by a different process.

  • Bond, F. W. & Bunce, D. (2000). Mediators of change in emotion-focused and problem-focused worksite stress management interventions. Journal of Occupational Health Psychology, 5, 156-163.


    Randomized controlled trial. Shows that ACT is more effective than a previously empirically supported behavioral approach to reducing worksite stress and anxiety, and that both are better than a wait list control. Process analyses fit the model.

  • Zettle, R. D. (2003). Acceptance and commitment therapy (ACT) versus systematic desensitization in treatment of mathematics anxiety. The Psychological Record, 53, 197-215.


    Small randomized controlled trial shows that ACT is as good as systematic desensitization in reducing math anxiety, but works according to a different process. Systematic desensitization reduced trait anxiety more than did ACT. The study has been replicated with interesting results:

    Brown, L. A., Forman, E. M., Herbert, J. D., Hoffman, K. L., Yuen, E. K. and Goetter, E. M. (2011). A randomized controlled trial of acceptance-based behavior therapy and cognitive therapy for test anxiety: A pilot study. Behavior Modification, 35, 31-53. Very small RCT (N = 16) for test anxiety comparing ACT (with mindfulness elements) and Beck’s CT. Similar outcomes on self-reports but ACT participants did objectively better on test scores in school.

  • Forman, E. M., Hoffman, K. L., McGrath, K. B., Herbert, J. D., Brandsma, L. L., & Lowe, M. R. (2007). A comparison of acceptance- and control-based strategies for coping with food cravings: An analog study.Behaviour Research and Therapy, 45, 2372-2386.


    98 participants with chocolate cravings were exposed to a well known CBT-based protocol (Kelly Brownell’s LEARN program) and an ACT-based protocol or no instructions and required to carry chocolate with them of for two days. Those more impacted by food related cues ate less and had fewer cravings in the ACT condition.

  • Masedo, A. I. & Esteve. M. R. (2006). Effects of suppression, acceptance and spontaneous coping on pain tolerance, pain intensity and distress. Behaviour Research and Therapy, 45, 199-209.


    A large and well-controlled randomized study that replicated Hayes, Bissett, Korn, Zettle, Rosenfarb, Cooper, & Grundt, 1999. Acceptance methods drawn from the 1999 ACT book and from the Hayes et al. 1999 pain study (the methods used included an acceptance rationale, practicing awareness of experience, the “Passengers on the Bus” exercise, and the ‘Two Scales Metaphor’) increased pain tolerance and decreased pain ratings in a cold pressor task as compared both to suppression methods (based on thought stopping) and to participants preferred method of coping (which tended to include distraction, relaxation, and keeping the hand still). The latter two conditions did not differ from each other in the main analysis.

    Wetherell, J. L., Afari, N., Rutledge, T., Sorrell, J. T., Stoddard, J. A., Petkus, A. J., Solomon, B. C., Lehman, D. H., Liu, L., Lang, A. J., Hampton Atkinson, J. (2011). A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. Pain, 152, 2098-2107. DOI: 10.1016/j.pain.2011.05.016 RCT (N=114) comparing ACT and traditional CBT for chronic pain. Good outcomes over 6 months. No differences in outcomes. Treatment completers were more satisfied with ACT.


    Thorsell, J., Finnes, A., Dahl, J., Lundgren, T., Gybrant, M., Gordh, T., & Buhrman, M. (2011). A comparative study of 2 manual-based self-help interventions, Acceptance and Commitment Therapy and Applied Relaxation, for persons with chronic pain. The Clinical Journal of Pain, 27, 716-723. doi: 10.1097/AJP.0b013e318219a933. RCT (N = 90) of ACT versus applied relaxation using a combination of an initial face to face session, a 7 week self-help manual with weekly therapist telephone support, and a concluding face-to-face session. 6 and 12 mo follow up. Better outcomes for ACT in level of function, pain intensity, acceptance, and marginal life satisfaction. Depression and anxiety improved but no diff between conditions.


    Rost, A. D., Wilson, K. G., Buchanan, E., Hildebrandt, M.J., & Mutch, D. (in press). Improving psychological adjustment among late-stage ovarian cancer patients: Examining the role of avoidance in treatment. Cognitive and Behavioral Practice. RCT (N = 31; 47 originally but the rest died or entered hospice care) comparing ACT and traditional CBT approaches to women coping with end-stage gynecological cancer. Nice outcomes; dominantly in favor of ACT. By the way CBT is labeled "TAU" -- you have to look at the list of procedures to see that it was CBT.


    Arch, J., Eifert, G. H., Davies, C., Vilardaga, J. P., Rose, R. D., & Craske, M. G. (in press). Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for mixed anxiety disorders. Journal of Consulting and Clinical Psychology. RCT (N = 128; 52% female; 33% minority) of 12 sessions of ACT v. tradition CBT for heterogeneous anxiety disorders; both including behavioral exposure. Similar outcomes in several areas through 12 mo F-up but on the primary outcome measure -- blind clinical interviews on the clinical severity of anxiety problems using the ADIS interview -- ACT participants improve more in clinical severity from post to follow up than CBT (it is a very large effect: d = 1.33) and among completers their end-state clinical severity ratings were much better (d = 1.03). Better improvement for ACT in psychological flexibility (medium effect for completers: d = .59) for ACT; better quality of life at follow up (small effect: d = .43) for CBT. 


There are also studies showing that ACT methods can empower traditional behavioral methods, e.g.,

More recently studies have explained the effect of some cognitive variables in ACT terms, e.g.,

Some of the history of ACT, including its relation to CBT writ large, can be found in:

  • Zettle, R. D. (2005). The evolution of a contextual approach to therapy: From Comprehensive Distancing to ACT. International Journal of Behavioral Consultation and Therapy, 1(2), 77-89.