Common Misunderstandings About ACT / RFT

Here are a number of common misunderstandings about ACT and RFT and CBS. I've listed only ones that I think are demonstrably false. Ones that could be true I have not listed since this page is about misunderstandings, not legitimate weaknesses. Comments follow each. If you know of others, let me know - Steven Hayes

• ACT is just _____ (fill in your favorite: Buddhism, CT, BT, CBT, Logotherapy, a psychology of the will, Gestalt, existential, est, Morita, constructive living, solution focused therapy, Kelly role therapy, and so on and so on)
  Resemblance is a fun game to play but I have yet to have anyone say these things in strong form (it is just _____) when they have really delved into the philosophy, theory, data, and technology. It is actually a positive sign when you see that others are pointing to somewhat similar issues. If multiple paths lead in a direction perhaps that is a direction worth exploring. If folks want to draw the connections above, it would be good to do them seriously and in print so people can understand the connections. The only ones I could see myself fully agreeing to is "ACT is just behavior analysis" ... or, properly understood, "ACT is just behavior therapy," but I'd quickly want to add "but that area itself has to be understood in a different way to say that." As far as roots, some of these are indeed influences on ACT. You could find some historical connections with CT, BT, CBT, Logotherapy, Gestalt, existential, and est for example. Maybe Buddhism if you mean "estern thought" -- as a child of the 60's it would be hard to avoid that. Probably a few more and as it expands lots of new things come in. ACT is a vast community now.

• ACT is a cult
  James Herbert has a great powerpoint on this site walking through why that comparison is unfair and inaccurate. Cults are closed off; they avoid criticism; they are hierarchical; they suppress open expression. ACBS is the exact opposite in all of these areas.

• ACT is just the latest fad
  ACT will ultimately die, as will we all, and it may indeed do so in a matter of decades or sooner, as what is worthwhile inside it become better understood and enters into the mainstream (that process of assimilation is happening at light speed right in front of our eyes), but if you mean that it is frivolous or insubstantial, that is just factually incorrect. When you last 35 years, do over 1000 basic and applied studies, and train over 50,000 people, "fad" is just not an applicable term. Is it? Inside the ACBS community we suspect that the applied and basic theory underlying ACT  and RFT (etc) is wrong but that is because so far in science all theories have ultimately been shown to be incorrect. We just don't know where it is wrong yet ... but we are chasing that rabbit! Come help us prove ourselves wrong!

• ACT is new on the scene
  It is just under 35 years old. The first ACT workshop was given in 1982 at Broughton Hospital in North Carolina.

• ACT is old on the scene and thus its outcome studies should be __ times more
  When I first posted this page in the early 2000s I had to explain our slow start, but now the criticism is just so far out of date even that explanation seems unneeded. OK, here is the explanation I used to give: ACT followed a different development path linked to philosophy, basic research, and process measurement. There was a 14 year gap in outcome studies from 1986 to 2000. That gap should not be held against the tradition because the detour was linked to even higher standards and goals. During that time, functional contextualism, the psychological flexibility model, RFT, measures of psychological flexiblity, and a contextual behavioral science approach were created -- and it seemed responsible to do that before larding up with RCTs after the first 3 successful ones in the mid 1980s. ACT is willing to be held to RCT-linked standards but RCTs alone are not enough to create a progressive field. You need a theory and development strategy that works. Once we had that better worked out we did indeed come back to outcome studies. If you look at the outcome studies since 2000 it would be a hard case to make that ACT does not care about outcome data. In 2000 there were 3 RCTs in ACT but it began to pick up in the mid 2000s. When I first rewrote this page as 2011 began it was up to 37 RCTs. Wow. Now it is five years later and I'm rewriting the page again in early 2016. The number of RCTs is hard to say precisely because a new one appears every week or less and no one can keep up anymore and still have a life. My best guess is that it is sliding past 200 (I have 153 in a file but a new paper my students wrote for a class tells me that there are about 70 more studies I missed that are not in English). And meanwhile ACT has more and more consistent mediation outcomes than any approach in existence. Our guess is over 50 studies. And it is the ONLY psychotherapy with a vigorous basic science of cognition underneath it, with hundreds of studies on RFT. An entire book has been written on the ACT Research Journey (Hooper & Andersson, 2015: http://www.amazon.com/Research-Journey-Acceptance-Commitment-Therapy/dp/1137440163/ref=sr_1_1?s=books&ie=UTF8&qid=1459110186&sr=1-1&keywords=ACT+research+journey). So, really, anyone suggesting we are slack in terms of research just does not know what he or she is talking about. Counting all areas of CBS my best guess based on search engines is that there are over 2000 studies if you apply a liberal set of search criteria and about 1000 if you apply a strict set. 

• ACT seeks ridiculously high goals and thus is making grandiose predictions or claims. Aspirations are not predictions or claims. Seeking a comprehensive account of behavior that would apply to all human action has always been the goal of behavior analysis as is shown in things such as Walden II. Why is a grand aspiration grandiose?

• ACT works only with the well-educated
  There are many trials indicating ACT is helpful for those who are poor, uneducated, intellectually disabled, children, those diagnosed with psychotic disorders, and so on and on. This criticism comes because the theory can be hard to understand (especially RFT). But we do not teach theory to client, we do therapy. That is different.

• ACT works only for white middle class Americans
  There are ACT studies from 15 countries includinging countries in Asia, the Middle East, and Africa. Successful studies have been done with poor urban black populations; unemployed poor Asian American populations; institutionalized South African blacks, etc. As of early 2016 there are 45 RCTs done on ACT in Iran; over 30 RCTs in Korea. The outcomes are equally good. The criticism is simply invalid.

• ACT is not committed to science
  Come on; wake up. Put in key ACT and RFT terms into the Web of Science or Google Scholar and look at what is out there dude. Download the studies. It after you do all that you repeat this claim that within arm's reach of me or you'd better be able to duck fast.
• The ACT research base is weak
  ACT has drawn a lot of interest from funded researchers and ACT funded studies are as good as any out there. There are a lot of them too (perhaps 50 RCTs of that kind) and the outcomes are often (not always) impressive. Yes, in some areas the research base is lean -- but ACT is not just for one problem area. In some areas, such as smoking or chronic pain, you'd have to distort the meaning of evidence to say that they ACT research base is weak. And these are areas where people have worked for years to dial in how to move ACT processes. So overall the research base seems impressive given the scope of ACT work. Having said that, we need to add three things. First, ACT draws a lot of interest from students, the developing world, or parts of the developed world without a grant infrastructure. These studies often have methodological issues (sample size; controls; etc) but jeez, how do they DECREASE what we know if they ADD to what we know from the best studies? Can someone please explain that to me? It happens IMHO only if people doing meta-analyses average methodology ratings. I'm sorry, that is just a dumb idea. Sure, weight findings study by study in light of methodological issues. But if a person in Liberia shows that ACT is helpful for problem x, and a huge grant-based study at a Western academic medical center with all of the bell and whistles showed that ACT is helpful for that same problem, the one in Liberia added to what we know regardless of its weaknesses. It showed that these approaches to not just apply to the western world, for one thing. It is fine to use the well controlled one to estimate effect sizes. But don't average the methodology ratings from the two and then say that the overall knowledge is weak in problem area x because the average methdology score is humble. Aaaagh. That is just stupid. Second, you need a string of studies in a given area with a given population to learn how to move psychological flexibility processes. If the technology has weak outcomes but did not move the processes, that is an unfortunate technology error, not a model failure. If you move the processes and the outcomes are poor that is a model failure. Yes, there are technology failures in ACT, but usually with new populations, settings, or modes of delivery. I know of no replicated model failures in 35 years of ACT / RFT / CBS research. Finally, some meta-analyses are biased. They are. Look at the overall pattern of meta-analyses and look carefully for responses to meta-analyses. For example, Ost claimed in 2008 that 13 ACT RCTs were weaker than 13 matched CBT RCTs; but then Gaudiano showed that effect was 100% due to grant funding, and furthermore 12 of the 13 ACT studies published mediational outcomes while 1 of the 13 CBT studies did so. An objective reader should reject Ost's comparison. You have to look at the criteria too. For example, if you rightly put "well defined population" on a list of methodological criteria, and then in small print insist on a DSM diagnosis as the only metric for a "well defined population," ACT will look methodologically weaker due to intellectually defensible choices that the reader might not realize is at play. CBS researchers generally despise the DSM. Including such a scoring approach behind an item will lead to a biased "criterion" (one that even NIMH has abandoned!). But the reader has to dig deep to sniff out bias liek that when it is there -- and sometimes not matter how much care, the reader will be bamboozled (e.g., if the ratings themselves have horrible kappas that are not reported). But the ACT community does not lay back on such things. We keep asking for the information and we keep trying to understand findings. As a reader: Keep your powder dry; be careful before leaping; look at the entire set of criticisms, responses, and meta-analyses; use your best judgment.

• ACT is just a technology
  It is a far more ... do your reading. It is a model linked to a philosophy, basic science, and a strategy of development.

• ACT is just a philosophy
  Ditto.

• ACT is just acceptance
  Ditto.

• ACT is just commitment
  Ditto.

• ACT is just acceptance and commitment
  Aw, come on. This kind of thing comes from folks reading the titles of books and studies instead of books and studies.

• Acceptance is important because it is a way to change the content of emotion (so ACT is really about that)
  The data suggest otherwise. Emotion do often change, but that change predicts behavioral outcomes more poorly than changes in the functions of emotions -- and sometimes good outcomes come without a change in emotion within the extant ACT literature.

• Defusion is important because it is a way to change the content of thought (so ACT is really about that)
  Double ditto. Same point. Also decent data supporting it.  Will thoughts change? Sure! RFT is all about changing thoughts and of course ACT changes thoughts.

• The ACT model of cognition is no different than any CBT model -- it is just different in its terminology
  If you believe that, have the courage to do your homework in detail and write it up in article form. Then be prepared to have others go after your ideas. We have so far responded to every single serious criticism in print in ACT or RFT, so anyone can read the criticisms and the response and judge the arguments. So far no one, I mean no one, has made the claim above in a careful scholarly article. But it is not the ACT world's obligation to prevent the claim from being made in the hallways of convention hotels or on listserves. Even here we do what we can, however. You are reading exhibit A in that area.

• Defusion is just distancing as that concept is used in CT
  They are indeed related. That is one of the real historical sources of ACT. But in ACT there are scores of such techniques, the are emphasized a great deal, and they are put to a quite different purpose than in traditional CT.

• ACT is just mindfulness as that concept is used by Buddhists or ______ (fill in the blank)
  ACT is clearly broader at the level of theory and technology. Mindfulness is itself a broad term that ican be vague if it is left at that level. That is why we have written 4-5 articles walking through the concept of mindfulness and trying to come up with a tighter analysis of it. When defined in the right way, ACT is a mindfulness-based approach but it is more than that as well.

• Defusion is just exposure in a traditional sense
  Research shows that defusion supports exposure. If you say it is exposure then you have expanded exposure to conver most contact of human beings with events and that is troublesome. Besides exposure itself is not well understood, and ACT folks have a flexibility and pattern-based account of exposure that comports with the ACT model.

• Acceptance is just exposure in a traditional sense
  Research shows that it supports exposure and appears to empower the impact of exposure. ACT is an exposure-based technology and we said in the first chapter on ACT in 1987. But the ACT view of exposure is that it is organized contact with previously repertorie narrowing events for the purpose of creating response flexibility. That is why our goal is teaching more flexible contact with private events and more flexible patterns of responding. We want patients to be able to label emotions; to feel them openly; and to be able to approach their values in action. The most recent work in traditional exposure in CBT is finally catching up that approach. We do not do exposure to reduce emotions (thought they usually are reduced) -- but it turns out that is not why exposure works even in traditional CBT.

• ACT does not care about the relationship
  We have a model of it; we teach it; we emphasize it. We have data showing that ACT gets high aliance scores; they predict outcome; but they are themselves explained in part by changes in acceptance/defusion/valued action. So no only do we care about the relationship, we care enough to be able to teach clinicans how to create powerful ones: create a psychologically flexibile relationship.

• ACT eschews meditation and contemplative practice
  Contemplative practice is often in our protocols (about 40% of the RCTs); Guided meditations is in nearly 100% of the protocols; ACT targets mindfulness at the level of process in multiple ways; it moves and is mediated by these processes; psychological flexibility impacts the brain or telomere length (etc) similarly. Now if you insist that mindfulness = sitting and following the breath, yes ACT is mostly not that. But if you insist on that narrow definition you now have to go to war with ancient mindfulness traditions too. Is a koan about mindfulness? Is chanting? This is why I resisted the word "mindfulness" in early ACT writing. I did not want to enter into arguments that were thousands of years old. ACT cares about mindfulness as a process.

• You should not mix behavioral procedures with ACT
  The model says you should. ACT is part of behavior therapy. With all due respect, you don't get to peel it away from its model just because that makes you uncomfortable in your sorting of things into cubby holes.

• If you do mix behavioral procedures with ACT you now have a combined treatment
  ACT is a model. Since the model says you should do this, it does not become a combination treatment to follow the model. In early ACT work we often deliberately hobbled the model so we could be heard by others (e.g., taking out formal exposure in studies on OCD). Times up. After 200 RCTs, no more hobbling the model to avoid science critics and their cubby holes.

• The other aspects of ACT add nothing to the behavioral elements
  We know that these other elements are helpful and that they can support the behavioral elements. If you mean that the other elements are inert, that is clearly untrue. We published a meta-analysis of the first 60 or so component studies and all of the components matter [Levin, M. E., Hildebrandt, M. J., Lillis, J., & Hayes, S. C. (2012). The impact of treatment components suggested by the psychological flexibility model: A meta-analysis of laboratory-based component studies. Behavior Therapy, 43, 741–756. DOI: 10.1016/j.beth.2012.05.003.]  More formal component analysese are beginning to appear [Villatte, J. L., Vilardaga, R., Villatte, M., Vilardaga, J. C. P., Atkins, D. A., & Hayes, S. C. (2016). Acceptance and Commitment Therapy modules: Differential impact on treatment processes and outcomes. Behaviour Research & Therapy, 77, 52-61. doi:10.1016/j.brat.2015.12.001]. And we know that all of the aspects of the psychological flexibility model contribute to outcomes (McCracken and colleagues have a study on that in the chronic pain area).

• The data on traditional CBT is far stronger
  Well, duh. Your father's retirement account is bigger than yours too. ACT is part of the CBT / BT / BA family but its specific research program takes a large community to mount.  The CBS community is focused on basic science, processes of change, micro-studies, prevention, social change, link to evolution science, and so on and on. But dig deeper. The vast majority of what is specifically supported in traditional CBT is stuff that ACT folks agree with anyway. If you insist on drag race studies --OK. Be patient. But you can't start outcomes studies in 2000 and expect 16 years later to have the same amount of data as the biggest dog on the block. But our research productivity is now obvious for anyone to see. If you know how to de searches 

• It is surely safe to mix ACT techniques with other techniques I'm more comfortable with while I wait passively to understand the model
  Ah, no. Down that path lies chaos. It is such a poor model of scientific development. Understand first. Get the data. Then add anything that makes sense for good theoretical and practical reasons, not just because you feel like it. One great benefit we have in ACT: if the thinks you like to do already improve psychological flexibility (measure it regularly) than by all means include those things.

• When I do that I should be able to rename it and get famous tomorrow because what I added (here you can pick any of the other misunderstandings -- relationship, emotion, mindfulness, etc etc) is obviously missing from the model
  You can rename it and still come and talk at our conventions etc. We don't care about names. Some folks in the CBS community call ACT "Acceptance Based Behavior Therapy" for example. It turns out that psychological flexibility still mediates the outcomes.  But branding helps people find the work so at least rename it for a good reason (e.g., sometimes it make it hard to do meta-analysises). It's up to you.

• You can mix ACT with the cognitive elements of CT / CBT easily
  With some, but be careful. Incoherence is not usually helpful and patients will detect the incoherence if it is there.

• It is safe to do research on ACT without doing any training in ACT
  Is it safe to do surgery that way? You cannot read a book and do this well. Get some training. It is cheap and available and non-proprietary. ACT folks will collaborate and consult. Reach out.

• It is safe to criticize ACT based on what you've heard about it from others who are not expert in it
  What is it about reading carefully that is so aversive?

• ACT contains nothing new
  If you've studied it thoroughly, just say it in print and say why you say that and let us all look at it dispassionately. If you've not done your homework yet, see above.

• ACT is behavioral in an S-R sense
  ACT is actively hostile to S-R psychology.

• ACT is behavioral in a traditional behavior analytic sense
  ACT / RFT is part of behavior analysis, but RFT changes everything. ACT is part of post-Skinnerian behavior analysis -- which is a new form. We call it "contextual behavioral science." Read the RFT book for why we say that.

• For these reasons ACT is not oriented toward cognition
  200 studies on cognition later, how can folks still say that?! Come to a training at least.

• For these reasons ACT is not oriented toward emotion
  Come to a training! Watch some tapes! Go look at my TEDx talk: www.bit.ly/StevesFirstTED

• Because ACT is broadly applicable it is primarily based on a non-specific clinical process
  The theory says why it is broadly applicable and the process data so far say it is successful due to specific process changes. We now have socres of mediational analyses out or in press.

• Anything that works for such a broad range of problems must be bulls**t
  The theory says why it is broadly applicable. Who are you to say a priori what nature is like?

• There are not many outcome studies on ACT
  About 200 RCTs and scores more controlled time series designs and counting. 

• ACT / RFT is a small minority
  Maybe. But there are about 3000 folks on the ACT / RFT listserves and over 8000 in the association. ACBS is bigger than ABCT or ABAI. Its one of the the fastest growing associations of its kind out there. Besides, minority or not, we are speaking of ideas and data, not politics.

• ACT proponents make excessive claims that go beyond the data
  A quote would be nice.

• ACT is hierarchical and you have to pledge allegiance to a leader to be involved with it
  It's an open list serve; an open website; no certification of therapists; no cut goes to originators from members/trainers/etc; you can get our protocols for free; anyone can become a trainer. There are more ACT books by others than by the originators, by far. This is just so unfair. Its a cartoon, and an ignorant one at that.

• ACT processes have not been studied
  Download the list of studies and read them. We think our process data are stronger than just about any other approach in all of applied psychology, and our link to basic science is excellent.

• RFT can't explain anything other models of cognition cannot explain
  RFT researchers have explained phenomena that other approaches have had hard times with. For example, we are learning how to establish a sense of self, we know a lot about how metaphor works, we know a core process in human cognition. And it appears that RFT programs raise IQs more dramatically than anything else out there; it helps with acquisition of language in disabled children; it has better implicit measures than anyone; it can predict who will suceed for fail clinically; etc.

• RFT is just jargon
  How much have you carefully read so far? Until you read carefully you cannot distinguish jargon and a technical language. RFT has a techical language, but only when technical terms are needed. If you disagree, pick a technical term and show how it is the same as a common sense one. Maybe there was a slip.

• ACT is just jargon
  Same reaction as above.

• No one can understand RFT
  Do the RFT tutorial on this website. Yes the basic studies are damn hard to understand ... you are languaging about language and that is just confusing. But it is not beyond anyone reading this website. Physics is hard too -- so?

• No one can understand ACT
  You can. And "understanding" in a purely intellectual sense is not the point for clients anyway. Usually what therapists mean when they say this is that they are afraid that if they don't understand it thoroughly they can't do it effectively. Folks like Raimo Lappalainen have shown that ACT works even when delivered by beginning therapists who don't really understand it. In fact most of the outcome data on ACT was not done with experienced ACT therapists. It's a miracle these studies work at all -- but they do. Understsanding does help: we have studies 

• RFT has little to do with ACT
  ACT and RFT co-evolved. There are many, many links are there and in both directions. It is not a matter of point to point correspondence and it should not be if we are right and applied and basic science should relate in a reticulated way. 

• ACT folks don't want CT people to be involved and they look down on them
  Ask some CT people who got involved in ACT work what they think about how they were treated. Just ask.

• We don't know which components work because there are no dismantling studies
  ACT comes from an inductive tradition. Rather than wait decades for dismantling studies we've done over 60 technique building and micro-analytic studies (see the reference above) and every aspect of the model has at least some targetted research data. And we do have some studies that dismantle the methods to a degree (an example was listed above)

• I hate the enthusiasm of students who do these workshops -- it scares me
  We can all agree that enthusiasm is not the same as substance ... but suppose that enthusiasm is hostile to substance? Besides this concern itself sounds emotional so why let emotions substitute for data just because it is now your emotions we are talking about (it scares me) ? Be consistent. If enthusism creeps you out, try to make room for being creeped out, hang on to your legitimate skepticism, and follow the data.

• I just don't like ACT
  See above.

• Talk of spirituality in ACT is creepy
  It is treated as a naturalistic concept. ACT is not a religion.

• I don't want to be told my values
  ACT folks will never do that ... your values are your choice.

• There is no data on ACT in groups
  About a third of the RCTs on ACT are done in groups, so that means scores of studies.

• ACT works through the same process as ____ (fill in your favorite)
  Show me the actual research please. The reverse is much more likely to be true so far (the psychological flexibility model explains your favorite). But that is cool, no? Now that we know how things work we can chase the outcomes together.

• ACT is not self-critical
  Lurk on the list serve and see. Come to a WorldCon and see. 

• Steve Hayes is a jerk -- I saw him do a mean joke or a mean comment at ABCT or ABAI
  ACT is not Steve Hayes -- there are scores of leaders in ACT / RFT. Besides, distinguish the message from the messenger. Some of us are confrontational about intellectual issues, but we don't go after people or traditions: just ideas. The list serve NEVER has flame wars, and that includes toward others. We are just playing hard. Why not? It is fun and can be helpful. Not everyone inside CBS plays the same way. if you hate folks who like to argue, go to ACT talks (etc) by softer folks. As for mean humor, sometimes roast humor can slip across the line a bit, but we tease those we respect. In the ACT community we use humor to remind us all that this work is not about the muckity mucks (including those inside ACBS) ... it is a shared enterprise and everyone is part of it who wants to be part and is willing to bring science based values and caring to the table. If you come to an ACBS conference you will see that the ACT / RFT leadership is outright ridiculed in the "follies" and it is just great fun. Anyone has access to the stage. Even cognitive therapists! : )

• ACT is crazy (or my personal favorite variant since I'm writing this, Steve is crazy)
  Ah, finally you are getting somewhere. But as that Time guy said in 2006 in the last line of the story on me and on ACT  -- we may just be crazy enough to pull it off. If you are nutty enough to want to help us, come help us succeed!