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The Oxford Handbook of

Acceptance and Commitment Therapy

OX F O R D L I B R A RY O F P S YC H O LO G Y
AREA EDITORS
Clinical Psychology
David H. Barlow
Cognitive Neuroscience
Kevin N. Ochsner and Stephen M. Kosslyn
Cognitive Psychology
Daniel Reisberg
Counseling Psychology
Elizabeth M. Altmaier and Jo-Ida C. Hansen
Developmental Psychology
Philip David Zelazo
Health Psychology
Howard S. Friedman
History of Psychology
David B. Baker
Methods and Measurement

Todd D. Little
Neuropsychology
Kenneth M. Adams
Organizational Psychology
Steve W. J. Kozlowski
Personality and Social Psychology

Kay Deaux and Mark Snyder

OX F O R D L I B R A RY O F P S YC H O LO G Y
The Oxford
Handbook of
Acceptance and
Commitment Therapy
Edited by
Michael P. Twohig, Michael E. Levin,
and Julie M. Petersen

Oxford University Press is a department of the University of Oxford. It furthers

the University’s objective of excellence in research, scholarship, and education
by publishing worldwide. Oxford is a registered trade mark of Oxford University
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Published in the United States of America by Oxford University Press

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ISBN 978–0–19–755007–6
DOI: 10.1093/oxfordhb/9780197550076.001.0001
Printed by Sheridan Books, Inc., United States of America

CONTENTS
Contributors ix
Section 1 • Conceptual Foundation

1. Progression of ACT 3
Robert D. Zettle and Kelly G. Wilson
2. Implementing ACT as Contextual Behavioral Science 25
Emily K. Sandoz and Caleb Fogle
3. Primer on Basic Behavioral Principles 42
Thomas J. Waltz and Claudia Drossel
4. A Primer on Relational Frame Theory 77
Colin Harte and Dermot Barnes-Holmes
5. Clinical Behavior Analysis and RFT: Conceptualizing
Psychopathology and Its Treatment 109
Carmen Luciano, Niklas Törneke, and Francisco J. Ruiz
Section 2 • General ACT Methods

6. An ACT Approach to Assessment, Case Conceptualization,
and Treatment 145
Katrina M. Daigle, Mikala A. Grimaldi, Rebecca Schneider,
and Lisa W. Coyne
7. Psychological Flexibility 169
Clarissa W. Ong and Elizabeth H. Eustis
8. Acceptance 182
Rhonda M. Merwin, Ashley A. Moskovich, Angela Pisoni,
Sara Freeman, and Carly Onnink
9. Cognitive Defusion 206
Francisco J. Ruiz, Bárbara Gil-Luciano, and
Miguel A. Segura-Vargas
10. Present Moment Awareness 230
Matthew S. Herbert and Niloofar Afari
11. Self-as-Context 249
Louise McHugh and Alison Stapleton
v

[email protected]
Author Name.
12. Values in Acceptance and Commitment Therapy 271

Jenna LeJeune and Jason Luoma
13. Committed Action 295
Lance M. McCracken
Section 3 • Specific Applications of ACT

14. Depression 311
Jacqueline A-Tjak and Louise Hayes
15. ACT for Anxiety and Trauma-Related Disorders 333
Brooke M. Smith, Gregory S. Smith, and Ellen J. Bluett
16. Obsessive Compulsive and Related Disorders 353
Eric B. Lee, Myles Arendtson, and Andy Wall
17. ACT for Eating Disorders 372
Adrienne Juarascio, Paakhi Srivastava, Christina R. Felonis,
and Olivia B. Wons
18. Health Promotion and Weight Management for Obesity 391
Jason Lillis and Dayna Lee-Baggley
19. Acceptance and Commitment Training in the Workplace 407
Paul E. Flaxman, Arianna Prudenzi, and Lucie Zernerova
20. Acceptance and Commitment Therapy for Chronic Pain 432
Karlyn A. Edwards and Kevin E. Vowles
21. ACT for Chronic Health Conditions 455
Lilian Dindo, Julia R. Van Liew, and Joanna J. Arch
22. Acceptance and Commitment Therapy for Substance Use 483
Maria Stavrinaki, Megan Kelly, and Maria Karekla
23. Acceptance and Commitment Therapy for Smoking Cessation 501
Jonathan B. Bricker
24. ACT for the Treatment of Psychosis and Schizophrenia-Spectrum
Disorders 513
Brandon A. Gaudiano and Stacy Ellenberg
Section 4 • Implementation of ACT

25. Effective Training and Delivery of ACT: The Dissemination and
Implementation Issues 537
Robyn D. Walser and Emily Rachel Wharton
26. ACT in Schools: A Public Health Approach 564
Tyler L. Renshaw, Sean N. Weeks, Anthony J. Roberson, and Stephanie Vinal
27. ACT for Children and Adolescents 584
Julie M. Petersen, Louise Hayes, Duncan Gillard, and Joseph Ciarrochi
28. Technology 605
Raimo Lappalainen, Katariina Keinonen, and Päivi Lappalainen
vi C o n ten ts
29. ACT in Groups 641

Joanna J. Arch, Lauren B. Finkelstein, and Lilian Dindo
30. Cultural Adaptations of Acceptance and Commitment Therapy 662
Akihiko Masuda, Lucas Morgan, Samuel D. Spencer, Joanne Qinaʻau,
and Duckhyun Jo
31. Acceptance and Commitment Therapy Inside Behavior Analysis 680
Jonathan Tarbox, Amanda N. Chastain, and Thomas G. Szabo
Conclusion
32. Future Directions of Contextual Behavioral Science 711
Rikard K. Wicksell, Niklas Törneke, Lance M. McCracken, Jonathan B. Bricker,
Amy R. Murrell, Akihiko Masuda, and Anthony Biglan
33. Creating Progress in Contextual Behavioral Science: Overcoming the Hurdles
of the Past—Facing the Challenges of the Future 733
Neal Falletta-Cowden, Steven C. Hayes, and Michelle Forman
Index 755
Cont e nt s vii
CO N T R I B U TO R S
Niloofar Afari, PhD Joseph Ciarrochi, PhD

Professor, Department of Professor, Institute of Positive
Psychiatry, University of Psychology and Education,
California, San Diego Australian Catholic University,
Joanna J. Arch, PhD Austinmer
Associate Professor, Psychology Lisa W. Coyne, PhD
and Neuroscience, University of Assistant Professor, Psychiatry
Colorado, Boulder Department, Harvard Medical
Myles Arendtson, BA School, Boston
Graduate Student, School of Katrina M. Daigle, MA, MS, PhD
Psychological and Behavioral Candidate
Sciences, Southern Illinois Psychology Department, Suffolk
University, Carbondale University, Boston
Jacqueline A-Tjak, PhD Lilian Dindo, PhD
Clinical Psychologist, Associate Professor, Medicine,
A-Tjak Cursussen, Baylor College of Medicine,
Emmer-Compascuum Houston
Anthony Biglan, PhD Claudia Drossel, PhD
Senior Scientist, Oregon Research Associate Professor, Psychology,
Institute, Eugene Eastern Michigan University,
Ellen J. Bluett, PhD Ypsilanti
Clinical Associate Professor of Karlyn A. Edwards, PhD
Behavioral Science, Family Postdoctoral Fellow, Department
Medicine Residency of Western of Anesthesiology, Perioperative,
Montana, University of and Pain Medicine, Stanford
Montana, Missoula University, Palo Alto
Jonathan B. Bricker, PhD Stacy Ellenberg, PhD
Professor, Division of Public Health Clinical Psychology, Postdoctoral
Sciences, Fred Hutchinson Fellow, MindWell Center, Ithaca
Cancer Center and University of Elizabeth H. Eustis, PhD
Washington, Seattle Research Assistant Professor,
Amanda N. Chastain, MA, BCBA Department of Psychological
Senior Research Associate, and Brain Sciences Boston
University of Southern University, Boston
California, Los Angeles
ix
Neal Falletta-Cowden, MA Colin Harte, PhD

Psychology, Behavior Analysis, Postdoctoral Researcher, Federal
University of Nevada, Reno University of São Carlos, Brazil
Christina R. Felonis, BA and Paradigma –Centro de
Doctoral Student in Clinical Ciências e Technologia do
Psychology, Department of Comportamento, Brazil
Psychology, Drexel University, Louise Hayes, PhD
Philadelphia Licensed Clinical Psychologist,
Lauren B. Finkelstein, MA Director, DNA-V International,
Doctoral Student in Clinical University of Almería,
Psychology, Department of Melbourne
Psychology and Neuroscience, Steven C. Hayes, PhD
University of Colorado, Boulder Foundation Professor of
Paul E. Flaxman, PhD Psychology, Psychology,
Reader in Organizational Psychology, University of Nevada, Reno
Department of Psychology, City Matthew S. Herbert, PhD
University of London, London Research Psychologist and
Caleb Fogle, MS Assistant Professor, Research
Student in Clinical Psychology, Development Service and
Southern Illinois University, Department of Psychiatry,
Carbondale Veterans Affairs San Diego
Michelle Forman, MS Healthcare System and
University of Nevada, Reno University of California,
Sara Freeman, MS San Diego
LCMHC Therapist, Mood Dermot Barnes-Holmes, PhD
Treatment Center, Greensboro Professor, Department of
Brandon A. Gaudiano, PhD Psychology, Ghent University,
Professor Psychiatry and Human Belgium
Behavior, Brown University, Duckhyun Jo, MA
Providence Doctoral Student, Department
Duncan Gillard, DEdPsy of Psychology, University of
Senior Psychologist and Creative Hawaii, Honolulu
Director, Connect Wellbeing in Adrienne Juarascio, PhD
Education LLP, Bristol Assistant Professor, Department
Bárbara Gil-Luciano, PhD of Psychological and Brain
Associate Professor, Cofounder Sciences, Drexel University,
of Universidad de Nebrija, Philadelphia
Madrid Institute of Contextual Maria Karekla, PhD
Psychology (MICPSY), Madrid Assistant Professor, Department
Mikala A. Grimaldi, BS of Psychology, University of
OCD and Anxiety Behavior Cyprus, Cyprus
Specialist, Clinical Research Katariina Keinonen, PhD
Coordinator, New England Senior Lecturer, Department
Center for OCD and Anxiety, of Psychology, University of
Boston Jyväskylä, Jyväskylä
x C o n tr ibutor s
Megan Kelly, PhD Akihiko Masuda, PhD

Professor, Department of Professor, Department of
Psychiatry, University of Psychology, University of Hawaii
Massachusetts Chan Medical at Manoa, Honolulu
School, Worcester Lance M. McCracken
Päivi Lappalainen, PhD Professor, Clinical Psychology,
Postdoctoral Researcher, Department of Psychology,
Department of Psychology, Uppsala University, Uppsala
University of Jyväskylä, Jyväskylä Louise McHugh, PhD
Raimo Lappalainen, PhD Professor, School of Psychology,
Professor, Department of University College Dublin,
Psychology, University of Dublin
Jyväskylä, Jyväskylä Rhonda M. Merwin, PhD
Eric B. Lee, PhD Associate Professor, Department
Assistant Professor, School of of Psychiatry and Behavioral
Psychological and Behavioral Sciences, Duke University
Sciences, Southern Illinois Medical Center, Durham
University, Carbondale Lucas Morgan, PhD
Dayna Lee-Baggley, PhD Clinical Supervisor, Ola Lāhui
Registered Psychologist, Assistant Behavioral Health, Honolulu
Professor, Family Medicine, Ashley A. Moskovich, PhD
Dalhousie University, Halifax Assistant Professor, Department
Jenna LeJeune, PhD of Psychiatry and Behavioral
Licensed Psychologist, President Sciences, Duke University
Portland Psychotherapy Clinic, Medical Center, Durham
Training, and Research Center, Amy R. Murrell, PhD
Portland Licensed Psychologist and Affiliate
Michael E. Levin, PhD Faculty, Private Practice and
Professor, Department of Psychology, Department of Psychology,
Utah State University, Logan Murrell Psychological Services,
Jason Lillis, PhD LLC and University of Memphis,
Associate Professor (Research), Memphis
Alpert Brown Medical School, Clarissa W. Ong, PhD
The Miriam Hospital and College Research Scientist, Department
of Psychology, Providence of Psychological and Brain
Carmen Luciano, PhD Sciences, Boston University,
Professor, Department of Boston
Psychology, University of Carly Onnink, BS
Almería, Almería Research Assistant, Department
Jason Luoma, PhD of Psychiatry and Behavioral
CEO, Portland Psychotherapy Sciences, Duke University
Clinic, Research and Training Medical Center, Durham
Center, Portland
Contributors xi

[email protected]
Author Name.
Julie M. Petersen, MS Miguel A. Segura-Vargas

Doctoral Student, Department Graduate Student, Master’s
of Psychology, Utah State in Psychology, Theory and
University, Logan Research, Faculty of Psychology
Angela Pisoni, MA, PhD Candidate and Educational Sciences KU
Department of Psychiatry and Leuven, Leuven
Behavioral Sciences, Duke Brooke M. Smith, PhD
University Medical Center, Assistant Professor, Department of
Durham Psychology, Western Michigan
Arianna Prudenzi, PhD University, Kalamazoo
MSc, BSc Research Fellow, School Gregory S. Smith, PhD, BCBA-D
of Psychology, Institute for Assistant Clinical Professor,
Mental Health, University of Department of Applied Behavior
Birmingham, Birmingham Analysis, University of Dayton,
Joanne Qinaʻau, MA Dayton, OH
Doctoral Student, Department Samuel D. Spencer, MA
of Psychology, University of Doctoral Candidate, Department
Hawaii at Manoa, Honolulu of Psychology, University of
Tyler L. Renshaw, PhD Hawaii at Manoa, Honolulu
Associate Professor, Psychology Paakhi Srivastava, PhD
Department, Utah State Assistant Research Professor and
University, Logan Clinic Director, Center for
Anthony J. Roberson, PhD Weight, Eating and Lifestyle,
Assistant Professor, Department Drexel University, Philadelphia
of Clinical, Health, and Alison Stapleton, BA, PhD Candidate
Applied Sciences, University of School of Psychology,
Houston-Clear Lake, Houston University College Dublin,
Francisco J. Ruiz, PhD Dublin
Associate Professor, Faculty Maria Stavrinaki, PhD
of Psychology, Fundación Clinical Psychologist, Department
Universitaria Konrad Lorenz, of Psychology, University of
Bogotá Cyprus, Nicosia
Emily K. Sandoz, PhD Thomas G. Szabo, PhD, BCBA-D, LBA
BCBA, Emma Louise LeBlanc Assistant Professor, Department of
Burguieres/BORSF Endowed Psychology, Capella University,
Professor of Social Sciences, Minneapolis
Psychology Department, Jonathan Tarbox, PhD, BCBA
University of Louisiana at Associate Professor of Teaching and
Lafayette, Lafayette Program Director, Department
Rebecca Schneider, PhD of Psychology, University of
Assistant Professor, Department Southern California, Los Angeles
of Psychiatry and Behavioral Niklas Törneke, MD
Sciences, Emory University Psychiatrist, NT Psykiatri AB,
School of Medicine, Atlanta Köpingsvik
xii C o n tr ibutor s
Michael P. Twohig, PhD Sean N. Weeks, MS

Professor, Department of Doctoral Candidate, Department
Psychology, Utah State of Psychology, Utah State
University, Logan University, Logan
Julia R. Van Liew, PhD Emily Rachel Wharton, PsyD
Assistant Professor, Behavioral Psychologist, Palo Alto Veterans
Medicine, Medical Humanities, Affairs, Redwood City
and Bioethics, Des Moines Rikard K. Wicksell, PhD
University, Des Moines Associate Professor, Department
Stephanie Vinal, MS of Clinical Neuroscience,
Doctoral Student, Department Division of Psychology,
of Psychology, Utah State Karolinska Institutet,
University, Logan Stockholm
Kevin E. Vowles, PhD Kelly G. Wilson, PhD
Professor, School of Psychology, Professor Emeritus of Psychology,
Queen’s University of Belfast, Department of Psychology,
Belfast University of Mississippi,
Andy Wall, BS Oxford, Mississippi
Graduate Student, School of Olivia B. Wons, MS, PhD Student
Psychological and Behavioral Department of Psychological
Sciences, Southern Illinois and Brain Sciences, Drexel
University, Carbondale University, Philadelphia
Robyn D. Walser, PhD Lucie Zernerova, PhD
Assistant Professor, Staff Research Associate, Department of
Psychologist, Director, Psychology, City, University of
Department of Psychology London, London
University of California, Berkeley, Robert D. Zettle, PhD
National Center for PTSD, TL Professor and Director of Clinical
Consultation Services, Berkeley Training, Department of
Thomas J. Waltz, PhD, LP Psychology, Wichita State
Associate Professor, Department of University, Wichita
Psychology, Eastern Michigan
University, Ypsilanti
Contributors xiii
SECTION
1
Conceptual
Foundation

Progression of ACT
1
CH A PT E R
Robert D. Zettle and Kelly G. Wilson
Abstract
Acceptance and commitment therapy (ACT) in the context of its historical and
progressive development unfolded within three phases over the past 40 years. Events
and influences in an initial phase that culminated in the development of comprehensive
distancing as a precursor to ACT in the early 1980s preceded philosophical, theoretical,
and conceptual refinements that took place during the next phase of ACT’s progression.
These advancements, including the further explication of functional contextualism,
rule governance, and relational responding, contributed to the emergence of ACT as a
coherent transdiagnostic intervention by the turn of this century. Ever increasing outcome
and process research within the last two decades during ACT’s third and most recent
stage of progression have been instrumental in solidifying its current empirical status and
expanding globalization.
Key Words: history, comprehensive distancing, ACT, functional contextualism,

rule governance, relational frame theory
Progression of ACT
As reflected by its title, this article provides an overview of the current status of acceptance
and commitment therapy (ACT; S. C. Hayes, Strosahl, & Wilson, 2012) situated within an
historical account of the events that have led up to it. In short, we seek to show where ACT is
at the moment and the paths that it took to arrive there. We particularly offer an update of the
progression of ACT that has occurred since the initial publications concerning its development
10–15 years ago (Cullen, 2008; Zettle, 2005) and a more recent historical overview (Hooper
& Larsson, 2015, Ch. 3).
ACT is often presented most simply as the application of a psychological flexibility
model of human functioning comprising six interrelated processes: (1) acceptance,
(2) defusion, (3) flexible present moment awareness, (4) self-as-context, (5) chosen values, and
(6) committed action (S. C. Hayes et al., 2012). For our purposes here, we prefer to define
ACT as (1) a psychological approach to the alleviation of human suffering and the promotion
of human well-being, (2) based on functional contextualism, and (3) informed by relational
frame theory (RFT; S. C. Hayes, Barnes-Holmes, & Roche, 2001) as an associated account of
human language and cognition. We will accordingly refer to the progression over time in what
might be regarded as technical/methodological, philosophical, and theoretical dimensions or
strands within ACT, and how all three became integrated and interwoven with each other in
forging its identity and determining its current status. As will be seen, ACT as we know it
today, developed from a psychological approach known as comprehensive distancing (Zettle,
3
2005) that was philosophically based on radical behaviorism (Skinner, 1974) and informed
theoretically by Skinner’s (1969) conceptualization of rule-governed behavior.
Disclaimers
Before embarking on our journey, we would like to offer two disclaimers that are applicable
to any historical account such as ours. First, key events within such narratives are in hindsight
often presented in a more linear and coherent fashion (see Table 1.1) than how they actually
Table 1.1 Timeline of Key Events in the Progression of ACT

Date Event
1982 Rule-governed behavior is extended as a behavior-analytic conceptual model for
cognitive-behavioral interventions (Zettle & Hayes, 1982).
First laboratory analogue study of comprehensive distancing’s impact on pain tolerance
is conducted and presented (S. C. Hayes, Korn, Zettle, Rosenfarb, & Cooper, 1982).
1984 Results of first randomized clinical trial of comprehensive distancing compared to
cognitive therapy for depression are presented (Zettle & Hayes, 1984).
“Making Sense of Spirituality” paper is published describing deictic framing and process
of establishing transcendent perspective taking (S. C. Hayes, 1984).
1985 Introductory presentation of RFT (S. C. Hayes & Brownstein, 1985).
Observer exercise added to the comprehensive distancing protocol.
1986 Parameters of contextualism as a broader world view within which radical behaviorism
may be subsumed are presented (S. C. Hayes & Brownstein, 1986).
1987 First chapter-length presentation of comprehensive distancing (S. C. Hayes, 1987).
1989 Rule governance is fully reconceptualized within RFT (S. C. Hayes, 1989: S. C. Hayes
& Hayes, 1989).
1991 First uses of “acceptance and commitment therapy” (Wilson, Khorakiwala, & Hayes,
1991) and ACT (Wilson & Taylor, 1991) in paper presentation titles.
1993 Functional contextualism is proposed as the philosophical foundation for ACT
(S. C. Hayes, 1993).
First use of acceptance and commitment therapy in a publication title (S. C. Hayes &
Wilson, 1993).
1999 First book-length presentation of ACT published (S. C. Hayes, Strosahl, & Wilson, 1999).
2001 First-book length presentation of RFT published (S. C. Hayes et al., 2001).
2003 ACT and RFT list serves are started.
First World Conference on ACT, RFT, & The New Behavioral Psychology is held in
Linkoping, Sweden.
2005 Association for Contextual Behavioral Science is established.
Get Out of Your Mind and into Your Life published (S. C. Hayes, 2005).
2008 First meta-analysis of ACT published (Öst, 2008).
2011 Development of the Acceptance and Action Questionnaire-II (AAQ-II; Bond et al., 2011).
2012 The Journal of Contextual Behavioral Science is established.
Second edition of Acceptance and Commitment Therapy published (S. C. Hayes et al., 2012).
4 Ro b e rt D. Z ettle an d Kelly G. W ilson


[email protected]
Author Name.
unfolded in real time. Accordingly, the development of ACT might be more appropriately
viewed as the culmination of a reticulated process that more closely resembles solving a
challenging crossword puzzle (S. C. Hayes, Zettle, Barnes-Holmes, & Biglan, 2016) than
proving a geometric theorem. In particular, the delineation of functional contextualism did
not precede the formulation of RFT, which in turn, then resulted in the creation of ACT
(S. C. Hayes et al., 2016). Separate as well as coordinated progress in each of the three
dimensions or strands that define ACT contributed to its overall development. Some of these
advancements were more obvious and had rather immediate impacts, while others were more
subtle with delayed influences.
Second, the history we offer is uniquely our own; indeed, it is difficult to see how it could
be otherwise. The contributions and vision of single individuals are often critical in the devel-
opment of many therapeutic approaches that end up being “branded” [e.g., Freud (1916) in
the case of psychoanalysis and Beck (1976) for cognitive therapy], and ACT is no exception.
Accordingly, suffice it to say that we would not be writing this article had it not been for our
particular relationships with Steve Hayes that began at different junctures during the progres-
sion of ACT. Recently, he has reflected on some of his more personal experiences that were
instrumental in its origination (S. C. Hayes, 2019).
Our Histories
The relationship between Robert D. Zettle (RDZ) and Steve goes back to the fall of 1976
when both arrived at the University of North Carolina at Greensboro (UNC-G). RDZ was
beginning his first year in the clinical psychology program there, and Steve, who at the time
had not yet defended his dissertation, had just been hired as a new assistant professor and
assigned as RDZ’s faculty advisor. It quickly became obvious that the two shared an interest
from a behavior analytic perspective in better understanding the impact of human language
and verbal behavior on clinical phenomena. It was an influence that Steve acknowledges had
been ignited in him at least three years earlier by Willard Day (S. C. Hayes, 2001). RDZ
became Steve’s first doctoral student and for his dissertation completed what is retrospectively
commonly regarded as the first randomized clinical trial of what later came to be recognized
as ACT (Zettle, 1984). Both left UNC-G not long after its completion to accept academic
appointments, RDZ at Wichita State University and Steve at the University of Nevada, Reno
(UNR), where his relationship with Kelly G. Wilson (KGW) began.
KGW entered the graduate program in clinical psychology at UNR in the fall of 1989,
at which point the Reno lab was well established. Steve had brought several graduate stu-
dents with him from UNC-G and had attracted several others since his arrival at UNR in
1986. It was a highly productive time on multiple fronts. KGW’s interests mapped well onto
the breadth of lab interests at the time. He participated in qualitative clinical research on
proto-ACT inspired by Willard Day’s (1969) “behavioral phenomenology,” engaged in basic
human operant research on RFT (Wilson & Hayes, 1996), participated in seminars and con-
ferences aimed at fleshing out functional contextualism, published theoretical work on ACT
and RFT (S. C. Hayes & Wilson, 1993, 1994), and co-wrote and administered two National
Institutes of Drug Abuse (NIDA) funded grants, ultimately co-authoring the first book-length
ACT manual just prior to departing for an academic post at the University of Mississippi (S.
C. Hayes et al., 1999).
We hope that the account that follows will be sufficiently consistent and coherent to be
seen as plausible, while acknowledging that others who have been witnesses to and/or possible
contributors to the development of ACT have their own and possibly somewhat different
stories to tell. We thus make no claims that our narrative is “true” in the sense of elemental
Pro gre s sion of AC T 5

realism, although we have endeavored to appropriately document events and elements within
it whenever possible. Rather, we will defer to readers to determine where between fiction and
“history,” as that term is most commonly used, our account falls. Regardless of where it might
be placed, it may in our view be deemed as “true” to the extent that it is useful, as suggested
by Skinner (1980, p. 308) in his comparison of historical and fictional narratives: “In most of
the uses we make of history, fiction will serve as well. We demand consistency and plausibility
in lieu of truth and thus preserve what really matters, a bit of vicarious experience.” Like the
King advised in Alice’s Adventures in Wonderland, we will “begin at the beginning and go on till
[we] come to the end: then stop” (Carroll, 1865).
The Beginning: 1976–1986

In order to present the historical context in which ACT emerged, our story begins just as the
first wave of behavior therapy, which had been dominated by interventions based on operant
and respondent conditioning principles, was about to be replaced by a second wave featuring
cognitive-behavioral approaches (S. C. Hayes, 2004).
Rush et al. (1977) Paper

A key event in this transition, particularly given developments that had preceded it, was the
Rush, Beck, Kovacs, and Hollon (1977) randomized clinical trial, which favorably compared
cognitive therapy (Beck, Rush, Shaw, & Emery, 1979) to imipramine. This study was partic-
ularly noteworthy as it was the first one to report that a psychological approach was superior
to medication in treating a psychiatric disorder. By the time of its publication, the need to
more effectively address the role of human language and cognition in the initiation, main-
tenance, and treatment of abnormal behavior had become increasingly apparent to many
first-wave behavior therapists, especially those serving adult outpatients. At a theoretical/
conceptual level, however, more visible accounts of verbal-cognitive processes that had been
offered by disgruntled behavior therapists (e.g., Mahoney, 1974) were much more mecha-
nistic and mentalistic than behavior analytic in their orientation. At a technical level, related
ways of weakening the dysfunctional impact of language and cognition within what by now
had come to be regarded as “cognitive-behavior modification” (Meichenbaum, 1977) were
largely limited to thought-stopping (e.g., Rimm, 1973) and coping self-statements as part of
self-instructional training (Meichenbaum, 1972).
In our view, the Rush et al. (1977) paper transformed how behavior therapy was con-
ceptualized and practiced at the time for at least three reasons. One, any psychotherapeu-
tic approach shown to be more efficacious than pharmacotherapy, especially in treating
depression as the most common presenting adult outpatient complaint, understandably
received the attention of behavior therapists given their commitment to evidence-based
practice. Second, apart from distinctions drawn by Beck (1970) between cognitive and
behavior therapy, his treatment package included enough behavioral techniques, such as
activity scheduling (Beck et al., 1979, Chapter 7), with which behavior therapists were
already familiar, for it to be received as not too different or foreign. However, third and
perhaps most importantly, what cognitive therapy offered that was new, namely cognitive
restructuring, was a more sophisticated and apparently more efficacious means, relative to
thought stopping and self-instructional training, of altering the cognitive control of negative
thinking. Not surprisingly, cognitive restructuring as a treatment technique was soon added
to existing behavior therapy protocols, thereby giving rise to cognitive-behavior therapy
(CBT), even though its relative impact and ostensible mechanisms of action were later called

into question based on component and process analyses of cognitive therapy (Jacobson
et al., 1996; Zettle & Hayes, 1986, 1987).
Behavior Analysis and CBT

With the advent of this second wave of cognitive-behavioral approaches, any presence and
influence that behavior analysis had in the development and practice of operant-based
interventions within the first wave were diluted even further. It should be noted that Ferster
(1967, 1972) had offered a behavior-analytic perspective on verbal psychotherapy that has
since been cited as contributing to the development of functional analytic psychotherapy
(R. J. Kohlenberg & Tsai, 1991). However, this work, did not readily point to any innova-
tive changes to behavioral therapeutic practice at the time and by the mid-to late 1970s
had clearly been overshadowed by a number of the developments already discussed. As a
result, turning to the writings of Skinner (1957, 1969) appeared to be the most fruitful
approach to take by those wishing to mount a radical behavioral counter-response to the
conceptual challenges and practical changes presented by the “cognitive revolution” taking
place within behavior therapy.
Even though Skinner considered Verbal Behavior (1957) his most important work
(Salzinger, 1990), it became apparent that this work was of limited utility due to its focus on
the behavior of speakers while relatively neglecting that of listeners. In short, Skinner’s con-
ceptual analyses of speaking, for example, might help explain why a depressed client’s thinking
exemplifies Beck’s (1967, 1987) negative cognitive triad, but not why or how such thinking
then influences the emotional reactions and overt behavior of that same client as a listener.
Even more importantly, such a limited account had no substantive clinical value in guiding
effective ways to weaken such pernicious cognitive control.
By comparison, Skinner’s (1969) formulation of rule-governed behavior, especially when
modified and expanded, initially proved to be more useful in several respects in suggest-
ing a radical behavioral framework in which to conceptualize cognitive therapy and related
approaches (Zettle & Hayes, 1982). For one, it shifted more focus to the behavior of listeners,
including instances in which rule-followers and rule-givers share the same skin. A problematic
issue, however, quickly became apparent and was not completely resolved until later when it
was extensively addressed by RFT (see Barnes-Holmes et al., 2001, as well as Article 4 this
volume). This problem concerned Skinner’s (1966, 1969) topographical definition of rules
as “contingency-specifying stimuli.” When this issue was at least temporarily addressed by
recasting rules as verbal discriminative stimuli, rule-governed behavior more broadly could be
meaningfully reconceptualized as comprising three different functional units (pliance, track-
ing, and augmenting) under the control of two distinct sets of contingencies, one naturalistic
and the other arbitrary and socially mediated.
An expansive conceptual framework that pointed to multiple controlling variables for
rule-following, and to a lesser degree for rule formulation, had some rather important practical
and theoretical implications. For one, it suggested that coping self-statements may function as
plys, or rules whose following is mediated by a verbal-social community, and thus have lim-
ited efficacy unless delivered and followed in a public context. This finding had already been
reported (Zettle & Hayes, 1979) and subsequently replicated by other related studies (e.g., S.
C. Hayes & Wolf, 1984; Rosenfarb & Hayes, 1984).

Comprehensive Distancing
More importantly for the development of ACT, examining cognitive therapy through the
lens of rule governance also suggested a new therapeutic approach. This approach, referred
to as comprehensive distancing (CD), was further influenced by the personal struggles of S.
C. Hayes (2019) with panic attacks at the time. This forerunner of ACT sought to expand
the process of distancing from cognitions as the “first critical step” within cognitive therapy
(Hollon & Beck, 1979, p. 189) in which clients are encouraged to respond to their depress-
ing thoughts as mere psychological events rather than as immutable facts prior to restructur-
ing them. Many readers will recognize the similarities to emphases on acceptance, defusion,
and even mindfulness within ACT, and to what is more often referred to as “decentering”
(Bernstein et al., 2015; Safran & Segal, 1996) within mindfulness-based cognitive therapy
(Segal, Williams, & Teasdale, 2002).
Formulating rules, thinking, reason-giving (Zettle & Hayes, 1986), and similar verbal
activities from a behavior-analytic perspective cannot function as causes for other actions inso-
far as they cannot be directly manipulated (S. C. Hayes & Brownstein, 1986). Nonetheless,
they may participate in controlling relationships with other behavior when sufficiently sup-
ported by verbal-social contingencies. For example, a range of destructive and dysfunctional
actions may be socially acceptable when justified by a narrative of plausible reasons (S.
C. Hayes, 1987). This analysis further suggested the viability of creating a special verbal-social
community within the context of therapy in which deleterious cognitive control could be
systematically weakened, for example, through acceptance and defusion, without resorting
necessarily to change in cognitive content.
Initial empirical support for CD was provided by a laboratory experiment increasing
cold pressor-induced pain tolerance (S. C. Hayes et al., 1982) that was published 17 years
later (S. C. Hayes, Bissett, et al., 1999), a randomized clinical trial comparing it favorably to
cognitive therapy for depression (Zettle & Hayes, 1984), and a series of unsystematic case
studies (S. C. Hayes, 1987). While CD included many of the treatment components and
techniques that are commonly part of the contemporary practice of ACT, there were also
at least two noteworthy omissions. Behavioral homework was included in CD, but because
it was not linked to values, it ostensibly functioned more like mood-enhancing behavioral
activation (e.g., Martell, Addis, & Jacobson, 2001) than valued action. In short, relatively
speaking, CD was more of an acceptance and willingness therapy than an acceptance and
commitment to valued action therapy.
Also missing from CD was the Observer exercise (S. C. Hayes et al., 2012, pp. 233–237)
that is often used to complement the Chessboard metaphor (which was included) in fostering
self-as-context within ACT. This exercise was not added until at least two years later at the sug-
gestion of a graduate student in the Hayes lab (S. C. Hayes, personal communication, March
28, 2005), not coincidentally around the same time of the “Making Sense of Spirituality”
paper (S. C. Hayes, 1984). This publication is understandably included in a collection of
Hayes’s (2015) canonical papers and merits special mention as beginning the link that would
later be solidified between RFT and ACT. It makes no explicit mention of deictic framing, but
it elucidates the processes from which the “behavior of seeing seeing from a perspective” (S.
C. Hayes, 1984, p. 103) results in a transcending sense of self.
An even bigger boost in retrospect to the relationship being fostered between CD and
RFT occurred near the end of what might be regarded as ACT’s decade-long, initial devel-
opmental stage with the unveiling of RFT by S. C. Hayes and Brownstein (1985). Sidman’s
(1971) report of untrained equivalence classes that emerged between printed words and pic-
tures, as well as between spoken and printed words, in teaching reading to a teen with a severe

intellectual disability, was recognized as a prototype for how a more expansive repertoire of
arbitrary applicable relational responding could be acquired as operant behavior. The S. C.
Hayes and Brownstein paper also positioned RFT to ultimately subsume rule governance by
reconceptualizing rules as verbal stimuli that serve a discriminative function because of their
“participation in relational frames established by the verbal community for the purpose of
producing such effects” (1985, p. 19).
The End of the Beginning

In summary, by 1986, CD as a precursor to ACT had been developed as (1) a psycholog-
ical approach to the alleviation of human suffering, (2) based on radical behaviorism and
(3) informed by a theoretical model of rule governance. At this juncture, Hayes would relocate
to UNR to focus more during the next decade and a half on delineating functional contextual-
ism as a broader philosophical foundation for ACT and RFT as a related conceptual frame-
work in further informing its development. Unfortunately, on a sad and more personal note,
especially for RDZ, these advancements would occur without any further contributions from
Aaron Brownstein who suddenly passed away far too early in the spring of 1986 (Shull, 1986).
Aaron was an astute experimental behavior analyst, but one just as, if not even more interested,
in understanding complex human behavior, including clinical phenomena (e.g., Greenspoon
& Brownstein, 1967a, 1967b), as he was with the actions of rats and pigeons in Skinner boxes.
Although the present article cites only two references in which Aaron was Steve’s co-author,
with one of them (Hayes & Brownstein, 1986) published posthumously, both were founda-
tional to the development of functional contextualism (Hayes & Brownstein, 1986) and RFT
(Hayes & Brownstein, 1985), and thus, albeit less directly, major influences in the progression
of ACT as well. If there is an “unsung hero” in our story, he’s Aaron Brownstein.
Laying the Groundwork: 1986–2000

Grasping the progression of ACT during this period would be difficult without some under-
standing of the extraordinary social network in which the development occurred. Hayes came
to Reno in 1986 in a leadership position as the Director of Training of the Clinical PhD pro-
gram, later transitioning to Department Chair. Under his leadership, the behavioral presence
in the department grew with the addition of Bill and Victoria Follette to the faculty in 1989,
the founding of the Behavior Analysis Program by Linda Hayes in 1990, and the subsequent
hiring of behavior analysis faculty (L. J. Hayes et al., 2016). The department embodied an
extraordinary unity of purpose in the development of behavior analysis theoretically, philo-
sophically, and in various applications. Although there was considerable interest in ACT and
CD proto-ACT, which certainly drew the attention of incoming clinical students, that work
was very much a product of the behavioral thinking aimed at broadening and deepening the
behavioral tradition.
Steve and Linda Hayes were running a lab in tandem when KGW arrived, and the lab
meetings became as much a debate society as they were a place to organize the business of a
research lab. Assorted elements of the behavioral tradition were poured together there. Willard
Day, who had been a faculty member at UNR—had died in the spring of 1989, but his
entirely unique view of a behavior theory and philosophy was very much alive (Day, 1969). As
referenced earlier, Day had inspired Hayes to examine the behavior analysis of language deeply,
but he was also a serious student of the philosophy of science. Indeed, he had taken a sabbati-
cal year to travel to Oxford and read philosophy during the period in which Gilbert Ryle was
Waynflete Professor of Metaphysics.


[email protected]
Author Name.
Hayes’s move to Reno was not random. He joined the faculty there while Willard was still
alive and active, recognizing it as an historically appropriate place for developing a broad and
rich behavioral tradition. The examination of contextualism and a deeper look at pragmatism
were natural activities in that environment. That seriousness in the study of behavior theory
and philosophy was ever present in a series of seminars, one of which, co-taught by Steve
and Linda Hayes, focused solely on Steven Pepper’s (1942) work. The seminar contained five
students, Steve and Linda, as well as Jim Owen, a radical behaviorist faculty member from the
UNR Speech and Language Department. It was not so much a university course as it was an
ongoing debate as we examined psychology through the lens of Pepper’s work. There was no
unanimity of view. Table pounding, shouted arguments, and sometimes preposterous thought
experiments were common. Linda Hayes launched a series of small seminars throughout the
1990s with a distinctive Kantorian flavor on behavioral philosophy and verbal behavior. These
conversations were not confined to the lab and classroom. Rather, they spilled over into the
hallways, at lunch, evenings at the Hayes’s residence, as well as through social gatherings at
various homes of students and faculty organized under a series of names, including “Food and
Philosophy” and “Beer and Behaviorism,” that involved readings and discussions of wildly
varying topics relevant to psychology and philosophy.
It was in this context that the groundwork for ACT clinical innovation developed. The
broader fleshing out of clinical behavior analysis occurred in a context centered in basic behavior
analysis as well as in other perspectives on the use of behavioral thinking to applied problems.
Notably, both Bill and Victoria Follette brought with them considerable exposure to the work
of Bob Kohlenberg and a functional-analytic psychotherapy perspective (R. J. Kohlenberg &
Tsai, 1991). And of course, Barbara Kohlenberg was among the graduate students who had
come to Reno from UNC-G with Steve.
The Debut of ACT
By the early 1990s, the philosophical and theoretical systems in which CD had been situated
had been supplanted; radical behaviorism had been superseded by functional contextualism; and
a Skinnerian model of rule governance had been replaced with RFT. The stage was accordingly
set to transform CD into ACT. Comprehensive distancing was always something of a troubling
name. Insiders knew that the “distancing” in CD was not initiated to “get away from” troubling
thoughts or to get enough separation to see them more objectively and rationally. Instead, its
purpose was to create sufficient psychological space within which clients could make contact more
broadly with difficult emotional content. Such expanded contact might include recognition of
content patterning, contexts that provoked such content, connection of difficult content within
personal history, and critically, the functional role such content played in organizing behavior.
A name that requires an explanation is by its nature troublesome. The acronym ACT
emerged in the Hayes lab at Reno when a several week-long brainstorming session produced a
variety of acronyms, including CAT (contextual analytic therapy) and RAP (radical acceptance
psychotherapy). Our best recollection is that the acronym came first, perhaps as a scramble of
CAT. ACT had the right flavor as a therapy that was all about getting into action. The acronym
lent itself to the spirit of the work, but also as short-hand for the treatment: Accept, Choose,
and Take action. ACT also had the advantage that it could be spoken as a word consistent with
the treatment—act, not A-C-T. And ultimately as a therapy name, acceptance and commit-
ment therapy was intuitively understandable and consistent with the developing work.
Who actually came up with the ACT acronym and name is lost to KGW, who was
there, as well as to Steve Hayes, who was consulted. As best as we can document in official
conference programs, the first reference to acceptance and commitment therapy appeared in

the title of a paper presented at the Association for Behavior Analysis (ABA) conference in
May 1991 (Wilson et al., 1991). This would place the date of the name change to the fall of
1990, as this was the deadline for the ABA conference paper proposals. A few papers appeared
in the vitas at the November 1990 Association for the Advancement of Behavior Therapy
Conference; however, those were certainly title changes that happened at or right before
their presentations. It took another three years for the name “acceptance and commitment
therapy” to first appear in the title of a publication (S. C. Hayes & Wilson, 1994) rather than
conference presentations.
Apart from a mere alteration in name, some strategic and technical changes were made to
CD that resulted in ACT as we know it today. Probably the most prominent of these changes
was the addition of values to the protocols and the explicit linking of committed action to
values. Hayes’s personal struggle with panic was his entry point to ACT. KGW came to the
work while he was recovering from severe substance dependence; acceptance was important,
but purpose and meaning as described by Victor Frankl (1965) were central. Behavior thera-
pists are always interested in selecting the most potent available reinforcers. Understanding
them for verbally competent individuals necessarily required a behavioral examination of ver-
bally constructed values and interventions suited to that analysis. At the end of the 1990 aca-
demic year, KGW proposed a comprehensive examination on a behavioral analysis of Frankl’s
noogenic neuroses and constructed the first values protocols for a NIDA treatment develop-
ment grant in 1993. Values first appeared in published form in two articles appearing in The
Behavior Analyst (S. C. Hayes & Wilson, 1993; 1994).
Theoretical Developments
Following the publication of an entire book dedicated to Aaron Brownstein and rule-governed
behavior (S. C. Hayes, 1989), the reconceptualization that had begun with the Hayes and
Brownstein (1985) paper and expanded by Hayes (1987) moved even further away from a
traditional Skinnerian perspective to one that was more clearly based within RFT. Especially
noteworthy in this volume was a chapter written by Hayes and Hayes (1989) whose stated
purpose was “to apply a relational perspective to the issue of rule-governance. Behavior con-
trolled by verbal stimuli is a different kind of behavior because it involves different psycho-
logical processes” (p. 177). In this endeavor, several basic elements of RFT were referenced
that predated the expanded coverage they would later receive within the S. C. Hayes et al.
(2001) text; aka “the purple book.” In particular, mutual entailment, combinatorial entail-
ment, transfer of stimulus functions, and contextual control over relational responding (i.e.,
Crel and Cfunc) were all explicated in accounting for “the verbal action of the listener as a basis
for rule-governance” (p. 153).
This emergent thinking in rule governance and RFT was a hot topic within the lab at
Reno and spawned a variety of basic experimental laboratory research, including an experi-
mental analysis of the development of relational responding in infants (Lipkens, 1992). There
were also studies examining relational responding in complex human behavior, including
network structure (e.g., B. S. Kohlenberg, 1994; Wilson & Hayes, 1996), transformation
of motivational functions (Ju, 2000), and propagation and durability of networks among
pathology-relevant stimuli (Wilson, 1998). These studies represented a quite organic follow-
up from the dissertations that had been completed in Hayes’s lab at UNC-G on language
development, stimulus equivalence, and rule-governed behavior, including those by Devaney
(1985), Rosenfarb (1986), Wulfert (1987), and, importantly, the publication of David Steele’s

dissertation, which was arguably the first clearly relational frame theory-oriented experimental
analysis, (though it was not called RFT at the time; Steele & Hayes, 1991).
Philosophical Developments
Expanding beyond a strict Skinnerian conceptualization of rule-governed behavior quite
understandably led to a closer critical examination of radical behaviorism itself as the philo-
sophical framework within which it was embedded. The building out of a behavioral com-
munity at Reno provided a fertile environment for launching a theoretical and philosophical
discussion with similarly interested individuals from around the world, resulting in a series
of books and conferences, including Dialogues on Verbal Behavior (L. J. Hayes & Chase,
1991), Understanding Verbal Relations (S. C. Hayes & Hayes, 1992), Varieties of Scientific
Contextualism (S. C. Hayes, Hayes, Reese, & Sarbin, 1993), Behavior Analysis of Language
and Cognition (L. J. Hayes, Hayes, Ono, & Sato, 1994), and Investigations in Behavioral
Epistemology (L. J. Hayes & Ghezzi, 1997). In an edited volume focused on elucidating sci-
entific contextualism (S. C. Hayes et al., 1993), Hayes argued that contextualism as one of
Pepper’s (1942) four world views could be meaningfully divided into descriptive and func-
tional variants. While Skinner’s (1974) radical behaviorism clearly can be regarded as contex-
tualistic, Hayes regarded it as dogmatic in that it reflected the purposes of science to predict
and control behavior rather than Skinner’s own selection of that particular goal. Functional
contextualism in which goals are explicitly linked to the clearly articulated preanalytic values of
predicting and influencing behavior was instead recommended as a philosophical foundation
for psychological interventions, thus allowing for a functional contextualism with goals other
than prediction and influence.
Clinical Developments
During the 1990s, mainstream CBT was highly focused on treatment outcome studies. CBT
treatment protocols were devised for psychiatric diagnoses, with outcomes studied in random-
ized clinical trials (RCTs) funded by the National Institutes of Health (NIH). The workgroup
at Reno had taken a very different turn, as reflected in the intensive work on theory, philoso-
phy, and basic empirical work discussed previously. Although grant-funded RCTs were not the
focus, three NIH studies were funded during this time period that were all developmental and
exploratory in nature. The first study was a protocol development grant from NIDA funded in
1993 examining the application of ACT to poly-substance abuse, in which the first values pro-
tocols were formalized. That grant was followed by a subsequent RCT extending that protocol
development, funded in 1997. Both of these grants were directed by KGW. Finally, a study
involving the treatment of nicotine dependent participants was funded in 2000, spearheaded
by Elizabeth Gifford, that explored an integration of ACT and functional-analytic psycho-
therapy principles. Finally, Steve Hayes served as a consultant to a training project at a large
Seattle-based health maintenance organization. The result was an innovative field effectiveness
study in which the treatment was not studied per se, but rather the focus was the exposure of
a cohort of therapists to ACT training over an intensive year of training and supervision. The
study importantly involved a diverse mental health population being seen in primary care and
a community mental health clinic with neither fixed diagnoses nor protocol length (Strosahl,
Hayes, Bergan, & Romano, 1998).
In addition to these grant-funded efforts, small, unfunded dissertation studies examined
a broad array of presenting concerns in a variety of clinical settings. Bach (2000) tested a brief
protocol with patients presenting with psychotic symptoms at a regional psychiatric hospital.
Geiser (1992) treated chronic pain patients at a Reno pain clinic. This period also produced a

series of analogue studies examining components thought to be central to ACT, such as accep-
tance, thought suppression, and metaphor (Afari, 1996; McCurry, 1991; Pistorello, 1998;
Walser, 1998). Khorakiwala’s (1991) dissertation used a variant of Willard Day’s behavioral
phenomenology in a qualitative analysis of processes of change in proto-ACT.
From the start, the development of ACT was an iterative and reticulated process. ACT
development was never merely a therapy development project. Rather ACT began and con-
tinues to be a component of a much broader effort. The focus was on careful theory and
philosophy, enriched by experimental analyses, and qualitative research on therapy processes,
stretching from the lab to the clinic and back again. All this was with an eye toward laying a
foundation for a broadly applicable theory of human suffering, struggle, and its remediation.
This work did not go unnoticed. During the 1990s, Dermot Barnes-Holmes, soon joined by
Yvonne Barnes-Holmes, launched what would become the most productive human operant
lab in the world, beginning in Cork, Ireland. Frank Bond applied ACT principles to work-
place environments and published the first organizational behavior management application
of ACT, giving rise to a stream of related research (Bond & Bunce, 2000). Carmen Luciano
produced an active lab in Almeria, Spain, with research stretching from basic research to clini-
cal applications. All of these interactions, stretching from basic theory and philosophy, from
the lab to the clinic, culminated in the publication of the first book-length description of ACT
(S. C. Hayes et al., 1999) and set the foundation for a global treatment development effort.
Making a Mark on the World: 2000–Present

By this juncture in our story, the first book-length presentation of ACT had been published
(S. C. Hayes et al., 1999) and a comparable one covering RFT (S. C. Hayes et al., 2001) was
about to appear, leading to the international dissemination of ACT and a rather rapid pro-
liferation in several types of research related to it. In retrospect, such sudden growth and vis-
ibility, as will be seen, perhaps quite understandably eventually led to considerable pushback
by ACT’s critics and skeptics.
The Globalization of ACT

The Association for Contextual Behavioral Science (ACBS) was established in 2005 as the
primary organizational home for researchers as well as practitioners of ACT and RFT. Very
quickly, however, it also attracted an increasingly broader array of contextually minded
clinicians and scientists. ACBS currently has over 9000 members (n.d.-h) representing a
diverse range of interests within contextual behavioral science; including evolution sci-
ence, comparative psychology, climate change, the use of psychedelics, and psychodynamic
psychotherapy.
ACBS provides access to a wide array of materials and resources about ACT, including
notices of training opportunities, as well as postings of publications and assessment instru-
ments, in addition to treatment manuals and protocols. Even prior to the formal founding of
ACBS, a concerted effort had already been underway to disseminate ACT beyond its origina-
tion in the United States. Although ACBS was not incorporated until 2005, it was born in
tragedy. Steve Hayes was preparing to fly to Sweden to do a workshop for Psykolog Partners,
a Swedish company that provided a variety of mental health services. The day Dr. Hayes
was to fly, he got a call canceling his flight. In fact, every flight in the United States was can-
celed that day—Tuesday, September 11, 2001. Undaunted, Psykolog Partners went beyond
rescheduling the workshop and organized the first proto-ACBS conference, held in Linköping,
Sweden, in August 2003. Since 2006, when ACBS assumed responsibility for organizing world

conferences, over half of them by design have been held outside the United States—in the
United Kingdom, the Netherlands, Italy, Australia, Germany, Spain, Canada, and Ireland—in
an effort to make ACT research and practice more accessible to the rest of the world (n.d.-g).
While U.S. residents still constitute the largest membership subgroup within ACBS (17%),
as of this writing, another 92 nations, or roughly 47% of the world’s countries, from every
continent save Antarctica, are now represented.
ACBS has worked hard at inclusion. Membership dues are values-based. The member
gets to choose their dues, with individuals from wealthier countries being encouraged to pay
higher dues. The ACBS website is wiki, allowing all members to access and share treatment
and educational materials. ACBS has resisted certification of therapists. It does recognize ACT
trainers through a peer review process, but this is not a profit-making effort.
Evidence of the strategy’s success in establishing an international community is provided
by the current composition of 40 affiliated ACBS chapters worldwide (n.d.-f ). The major-
ity of them (i.e., 26, or 65%) are outside the United States and have been variously orga-
nized nationally (e.g., Argentina and Finland), regionally (e.g., Australia and New Zealand),
and, in some instances, by linguistic communities (e.g., Dutch speakers in Belgium and the
Netherlands and French speakers in Belgium and France). ACT has grown by resisting exclu-
sivity, instead promoting an organization of contextual therapies. Many of these chapters have
already hosted successful conferences of their own or have plans to do so, thus further increas-
ing ACT’s local and regional presence and influence. ACT’s international visibility has also
been increased, albeit to perhaps not the same degree, by the creation of organizational affili-
ates of ACBS (n.d.-e), as, for example, in Africa, India, the United Arab Emirates, and Western
Balkans; where chapters have not yet been firmly established. ACT’s increased globalization
and worldwide reach is reflected not only by the diversity of the ACBS membership list, but
over the past 5 years by 11 related intervention projects that have been conducted in countries
that appear on lists of low-to middle-income countries (ACBS, n.d.-c). One of the most
recent examples of this outreach was the implementation and evaluation of an ACT-based,
self-help intervention for South Sudanese refugees (Tol et al., 2020).
450
400 406
350
300 274
250
200
150
100
64
50
3 13
0
1985–2000 2001–2006 2007–2012 2013–2018 2019–2020
Figure 1.1 Cumulative Number of ACT Outcome Publications
Note. The figure includes “in press” publications listed as of May 2022 at https://contextualscience.org/ACT_Rando
mized_Controlled_Trials.


[email protected]
Author Name.
Research Progression of ACT

The increasing number of projects conducted in impoverished regions of the world has been
part of a broader exponential growth of ACT-related research within several domains occur-
ring over the last two decades. (see Figure 1.1)
Outcome research
For ease of discussion, we will provide separate overviews of research that has evaluated the
efficacy and effectiveness of ACT during this most recent stage of its progression.
Efficacy research
As seen in the accompanying figure, the number of publications from 1985 to 2000 (i.e., four)
that compared the efficacy of ACT to other interventions and/or various control conditions
increased by nearly 300% during the next 5 years. The growth has increased exponentially over
the last two decades to where there are as of this writing over 900 efficacy studies that have
either been published or are “in press.” Although measures of symptomatic relief have been the
primary outcome variables in such investigations, researchers increasingly have also examined
improvements in quality of life (S. C. Hayes, Luoma, Bond, Mausda, & Lillis, 2006) and, even
more recently, increases in flourishing as additional dependent measures in evaluating ACT’s
impact (Bohlmeijer, Lamers, & Fledderus, 2015).
By 2010, enough randomized trials of ACT had been accumulated that systematic reviews
and meta-analyses of its efficacy began appearing. Most of these initial evaluations, unlike later
and more recent ones (ACBS, n.d.-k), focused on ACT more broadly rather than on its treat-
ment of specific presenting problems (e.g., Veehof, Oskam, Schreurs, & Bohlmeijer, [2011]
for chronic pain, Bluett, Homan, Morrison, Levin, & Twohig, [2014] for anxiety disorders
and OCD, and Howell and Passmore [2019] for depression). Two meta-analyses that received
more attention and reaction within the ACT community than most were critical ones by Öst
(2008, 2014). In his first publication, Öst (2008) concluded that ACT trials did not merit
recognition as an empirically supported treatment, despite significant and moderate effect
sizes, because of a relative lack of methodological rigor compared to traditional CBT studies.
In response to a subsequent rejoinder to his criticisms (Gaudiano, 2009), Öst (2009) conceded
that ACT research was not funded at levels comparable to CBT trials, but maintained that
the American Psychological Association’s recognition of ACT as having “moderately strong”
empirical support for treatment of depression was unjustified.
A second and updated meta-analysis by Öst (2014) 6 years later was even more critical of
ACT. In this work, Öst concluded that there had been no methodological improvements in
outcome research over that period of time. Moreover, he noted a deterioration in overall effect
size, resulting in no basis for regarding ACT as a “well-established” treatment for any disorder.
A robust response from a team of ACT researchers (Atkins et al., 2017) that catalogued a
plethora of factual and interpretational errors that likely biased Öst’s conclusions was followed
by an equally spirited rebuttal (Öst, 2017) that to date has effectively ended the back-and-
forth sparring.
Perhaps both motivated by and despite Öst’s criticisms, ACT researchers have become
increasingly successful in obtaining external funding (ACBS, n.d.- i). Moreover, efficacy
research on ACT has progressed to the point that the Society of Clinical Psychology (SCP)
has recognized the therapy as an evidence-based treatment approach for multiple psychiatric
disorders. More specifically, SCP (Division 12 of the American Psychological Association)
has affirmed ACT’s transdiagnostic status by concluding that it enjoys strong empirical sup-
port in the treatment of chronic pain (n.d.-a), and modest support in addressing depression

(n.d.-b), mixed anxiety (n.d.-c), obsessive-compulsive disorder (n.d.-d), and psychotic symp-
toms (n.d.-e).
Effectiveness Research
One of the more noteworthy evaluations of ACT’s effectiveness within the last decade resulted
from its inclusion in a national dissemination and training initiative for treatment of depres-
sion implemented by the U.S. Department of Veterans Affairs (VA; Walser, Karlin, Trockel,
Mazina, & Taylor, 2013). What has been referred to as the “roll-out” has now trained hun-
dreds of VA therapists in ACT, who in turn, have implemented it with thousands of their vet-
eran clients. Indirect comparisons to controlled trials of ACT for depression (Zettle, 2015) as
well as to traditional CBT within the same VA program (Karlin et al., 2012) in both reducing
depressive symptoms and in enhancing quality of life have been favorable.
More recent research suggests that the effectiveness of ACT may be reasonably robust
when offered outside the United States in a group format for both inpatients and outpatients
with varying clinical presentations. Similar to the results of the VA roll-out, a German clinical
trial found that ACT and CBT were equally effective in treating inpatient depression (Samaan
et al., 2020), while an Australian study documented the effectiveness of ACT with a transdi-
agnostic outpatient sample (Pinto et al., 2017).
Process of Change Research

Beginning with the earliest outcome studies (Zettle & Hayes, 1986; Zettle & Rains, 1989),
ACT researchers have been committed to not only investigating its therapeutic impact, but
variables that may mediate such change (ACBS, n.d.-d). The most recent systematic review
of ACT mediational studies specifically focused on those published from 2006 to 2015 in
updating an earlier review by S. C. Hayes et al. (2006). Stockton et al. (2019) found general
support for ACT’s purported mechanisms of change but also noted some methodological
limitations. They reported that not all six processes posited to contribute to psychological
flexibility (S. C. Hayes et al., 2006) were examined to the same degree. Since the introduction
(S. C. Hayes et al., 2004) and subsequent revision of the Acceptance Action Questionnaire
(Bond et al., 2011) and translation into several different languages (ACBS, n.d.-a), accep-
tance has been the specific process that has received the most attention as a possible mediator
of therapeutic change. However, with the recent development of psychometrically sound
measures for self-as-context (Yu, McCracken, & Norton, 2016; Zettle et al., 2018), future
mediational research now has the means available to evaluate the full range of processes
within the model on which ACT is based.
Laboratory-Based Component Research

Investigations of ACT’s possible mechanisms of action have also progressed through
laboratory-based component studies. This strategy is a long-standing one within ACT-related
research, going back almost 40 years (S. C. Hayes et al., 1982), in which analogues of treat-
ment components linked to specific processes within the psychological flexibility model are
experimentally manipulated as independent variables. For example, participants have been
instructed to “just notice” and “make room” for distressing thoughts related to shock-induced
pain while continuing a valued task in investigating processes of acceptance and commit-
ted action (Gutiérrez, Luciano, Rodríguez, & Fink, 2004). As with the other ACT research
domains reviewed, a sufficient number of such analogue studies have been completed over
time to conduct meta-analyses of them. The most recent one of which we are aware found
broad-based support for the psychological flexibility model, with larger effect sizes noted for

component conditions that were more experientially based (e.g., use of metaphors and exer-
cises) than those presented by a rationale alone (Levin, Hildebrandt, Lillis, & Hayes, 2012).
Breadth of ACT Applications

The common depiction of ACT as a transdiagnostic approach (e.g., Dindo, Van Liew, & Arch,
2017; Muto & Mitamura, 2011) both reflects and obscures the wide array of presenting prob-
lems and concerns to which it has increasingly been applied over the last two decades. Such a
description appropriately underscores that ACT practitioners and proponents over the course
of its development typically have often opted for breadth over depth of coverage in applying it
to mental health conditions. This progression, for example, can be contrasted with that of cog-
nitive therapy that focused almost exclusively on establishing itself as a treatment of depression
before being extended to other disorders (e.g., Clark & Beck, 2010). While ACT for anxiety
and related concerns have received the most attention (ACBS; n.d.-k), it has, as noted earlier,
also demonstrated its efficacy in treatment of chronic pain, depression, obsessive-compulsive
disorder, and psychotic symptoms to be recognized by SCP as an evidence-based intervention
for these clinical presentations as well. Other behavioral health concerns addressed by ACT,
though less intensively, have included substance abuse, eating disorders, marital discord, bor-
derline personality disorder, and trichotillomania (ACBS, n.d.-k).
While ACT can thus be reasonably regarded as an efficacious transdiagnostic approach for
mental health concerns, doing so fails to recognize its expanded applications to medical condi-
tions and other areas of human suffering and functioning. ACT, for example, has shown ben-
efits in assisting those dealing with an array of medical and neurological concerns including
stroke, asthma, HIV, tinnitus, fibromyalgia, diabetes, smoking, cancer, and multiple sclerosis
(ACBS, n.d.-k). Going all the way back to the third published comparative outcome study of
ACT (Bond & Bunce, 2000), it has also addressed human concerns, such as worksite stress
management, which have presented themselves in more everyday contexts apart from mental
health centers and medical clinics. What has increasingly been referred to as acceptance and
commitment training (Moran, 2015), for instance, has been extended to job-site performance
and safety, parenting, and skill coaching, among other areas (ACBS, n.d.-k).
Insofar as ACT rests on a broad-based model of human functioning that highlights the
role of psychological flexibility, its breadth of application is not arbitrarily constrained. A fur-
ther reflection of this diversity is that the majority of the current 39 special interest groups
(SIGs) within ACBS (n.d.-j) are concerned with some aspect or dimension of ACT. Some of
the SIGs focus on particular presenting problems (e.g., ACT and Autism, Applying ACT to
Addictions, and Pain SIG), several are organized around specific populations (e.g., ACT for
Military, ACT for the Christian Client, and Aging in Context) or practice settings (e.g., ACT
in Education, College/University Student Mental Health, ACT in Primary Care), while still
others are composed of those with shared professional or personal identities (e.g., ACT and
Judaism, Occupational Therapy and ACT, and Social Work SIG).
Variety of Implementation Formats

Beginning with the publication of the first ACT-based, transdiagnostic self-help book (S.
C. Hayes & Smith, 2005), over the past decade and a half there has been a progressive increase
in developing creative ways to make the treatment approach more accessible and one that goes
beyond the traditional face-to-face, client-therapist format. These alternative delivery systems
have included the use of computer-based protocols, smartphones, apps, and other forms of
telehealth in addition to bibliotherapy (ACBS, n.d.-b). This trend is likely to accelerate fur-
ther, given the current global pandemic and its aftermath. A recent meta-analysis of self-help

as a format for delivering ACT documented small effect sizes for depression and anxiety that
were enhanced when supplemented with clinician guidance (French, Golijani-Moghaddam,
& Schröder, 2017). This overall evaluation parallels the conclusions of an even more recent
systematic review and meta-analysis of internet-based ACT (Thompson, Destree, Albertella,
& Fontenelle, 2021).
Forging a Mature Identity

A final sequence of events that occurred within the relatively recent history of ACT war-
rants inclusion in our narrative because of its impact in forming ACT’s mature self-identity.
If there was a single trigger for this process, it was the argument that ACT exemplified an
increasingly emergent third wave of CBT embracing the use of mindfulness and acceptance
strategies that also differed from the previous generation of more traditional CBT approaches
on both philosophical and technical grounds (S. C. Hayes, 2004). As noted, the philosophi-
cal foundation of ACT, in particular, is functional contextualism rather than some variant
of mechanism (Pepper, 1942) that appears to at least implicitly underlie most traditional
forms of CBT, such as Beckian cognitive therapy (S. C. Hayes, 2004). Additionally, ACT
and other third-wave approaches favor secondary change techniques to alter the function
or relationship that clients have with their problematic private events (e.g., defusion and
mindfulness practices) over seeking to modify their form or content (e.g., disputation and
cognitive restructuring).
The assertion that a new wave of CBT was occurring was greeted with rather passionate
and sometimes heated pushback from threatened proponents representing the second genera-
tion of more traditional CBT (Hoffmann & Asmundson, 2008). From our perspective, this
was a concerted effort to keep the young ACT whippersnapper in its place. What followed
was a rather predictable sequence in which ACT was summarily dismissed as nothing new or
different, and most certainly, nothing that was possibly better (cf. S. C. Hayes, 2008). One
argument that ACT was little more than old wine in new bottles asserted that it was not
that substantially different from both traditional CBT (Arch & Craske, 2008; Hofmann &
Asmundson, 2008) and Morita therapy (1998; Hofmann, 2008; Leahy, 2008).
The larger acrimonious debate about the identity of ACT and its status within the CBT
family, however, did serve as an impetus for more comparative research. This research ulti-
mately helped empirically resolve the debate in ACT’s favor and thereby help establish its
“street cred.” While outcome research typically found the efficacy of ACT to be compa-
rable to traditional CBT (e.g., Arch et al., 2012; Craske et al., 2014; Forman, Herbert,
Moitra, Yeomans, & Geller, 2007), thus supporting the criticism that ACT was not better,
related mediational research also was generally consistent in suggesting that at least some of
its mechanisms of action were uniquely different (Forman et al., 2012; Niles et al., 2014).
Perhaps the most telling reflection of the rapprochement that eventually emerged from this
maturational stage in ACT’s development is that two of the primary “combatants” during
this process are now collaborating in advocating a process-based approach to CBT writ large
that incorporates both shared and unique clinical competencies integral to both ACT and
more traditional CBT (S. C. Hayes & Hofmann, 2018).
Summary and Concluding Remarks

While we have concluded our narrative, it is hardly the termination of ACT’s ongoing story,
which will continue to be told by others into the future (see Article 32 this volume, for exam-
ple). As reflected by Skinner’s (1980) comparison of historical and fictional accounts, we hope
we have preserved “what really matters” about the progression of ACT. As we see it, that

would be an understanding of the historical and current contextual variables instrumental

in development of the therapy. A reticulated process interweaving the threads of technical/
methodological, philosophical, and theoretical/conceptual advancements informed by basic
and applied research findings began with humble efforts to view verbal psychotherapy through
a behavior-analytic lens. Over 40 years later, it has culminated in a therapeutic approach and a
related model of human functioning that has currently demonstrated an international impact
in alleviating human suffering and promoting well-being. This is an ongoing endeavor, how-
ever, with much more work to be undertaken and further progress to be made. In our view,
ACT has already shown considerable promise in meeting the challenge of the human condi-
tion (S. C. Hayes, Barnes-Holmes, & Wilson, 2014). We trust it will continue to do so as long,
as it does not forget where it came from while keeping an eye on the prize.
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The Oxford Handbook of

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Methods and Measurement

Personality and Social Psychology

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Section 1 • Conceptual Foundation

Section 2 • General ACT Methods

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12. Values in Acceptance and Commitment Therapy 271

Section 3 • Specific Applications of ACT

Section 4 • Implementation of ACT

29. ACT in Groups 641

Niloofar Afari, PhD Joseph Ciarrochi, PhD

Neal Falletta-​Cowden, MA Colin Harte, PhD

Megan Kelly, PhD Akihiko Masuda, PhD

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Julie M. Petersen, MS Miguel A. Segura-​Vargas

Michael P. Twohig, PhD Sean N. Weeks, MS

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Robert D. Zettle and Kelly G. Wilson

Key Words: history, comprehensive distancing, ACT, functional contextualism,

Table 1.1 Timeline of Key Events in the Progression of ACT

4 Ro b e rt D. Z ettle an d Kelly G. W ilson

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Pro gre s sion of AC T 5

The Beginning: 1976–​1986

Rush et al. (1977) Paper

6 Ro b e rt D. Z ettle an d Kelly G. W ilson

Behavior Analysis and CBT

Pro gre s sion of AC T 7

8 Ro b e rt D. Z ettle an d Kelly G. W ilson

The End of the Beginning

Laying the Groundwork: 1986–​2000

Pro gre s sion of AC T 9

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10 Ro b e rt D. Z ettle an d Kelly G. W ilson

Pro gre s sion of AC T 11

12 Ro b e rt D. Z ettle an d Kelly G. W ilson

Making a Mark on the World: 2000–​Present

The Globalization of ACT

Pro gre s sion of AC T 13

Figure 1.1 Cumulative Number of ACT Outcome Publications

14 Ro b e rt D. Z ettle an d Kelly G. W ilson

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Research Progression of ACT

Pro gre s sion of AC T 15

Process of Change Research

Laboratory-​Based Component Research

16 Ro b e rt D. Z ettle an d Kelly G. W ilson

Section 1 • Conceptual Foundation

Section 2 • General ACT Methods

12. Values in Acceptance and Commitment Therapy 271

Section 3 • Specific Applications of ACT

Section 4 • Implementation of ACT

29. ACT in Groups 641

Neal Falletta-Cowden, MA Colin Harte, PhD

Julie M. Petersen, MS Miguel A. Segura-Vargas

The Beginning: 1976–1986

Laying the Groundwork: 1986–2000

Making a Mark on the World: 2000–Present

Laboratory-Based Component Research

Beck, A. T. (1987). Cognitive models of depression. Journal of Cognitive Psychotherapy, 1, 5–7.