International Journal of Cognitive Therapy (2019) 12:126–145

https://doi.org/10.1007/s41811-019-00043-9

ACT vs CBT: an Exercise in Idiosyncratic Language

James J. Collard 1

Published online: 15 April 2019

# Springer Nature Switzerland AG 2019

Abstract
Since the development of acceptance and commitment therapy as a therapy model,
there has been much debate about the similarities and differences between it and
‘second wave’ cognitive-behavioural practices (i.e. cognitive therapy, rational emotive
behaviour therapy). This article builds on these discussions, discussing the underlying
theoretical constructs relevant to the philosophy and practice of ACT and ‘second
wave’ CBT models. Ultimately, this results in the conclusion that there are more
similarities than differences between the two. Many of the espoused differences
between them appear to be due to the implicit versus explicit attentional foci of the
different models, and due to the development of idiosyncratic language by the different
authors. As a result, it would appear that there is more to be gained by bringing these
models together, to solidify the cognitive-behavioural framework and its application to
therapy.

Keywords Cognitive-behavioural therapy . ACT . REBT . CT

Since the development of acceptance and commitment therapy (ACT), there have been
a number of arguments put forth attempting to distinguish it from other cognitive
behavioural therapies, particularly in relation to elements of underlying theory and
philosophy (Hayes 2004, 2008; Hayes et al. 2013; Hayes et al. 1999). While some of
these have been identified to be misconceptions (e.g. that traditional cognitive
restructuring challenges rule governance by imposing further rules, not acceptance;
Hayes 2008), there are a number of issues that would benefit from further exploration.
This includes the similarities and differences between relational frame theory (RFT),
the underlying philosophy of ACT and traditional cognitive-behavioural philosophy. It
also relates to the exploration of the proposed theoretical mechanisms of change
between second wave cognitive-behavioural therapy (CBT) and ACT.

* James J. Collard
james.collard@cairnmillar.edu.au

1
School of Psychology, Counselling, & Psychotherapy, Cairnmillar Institute, Melbourne, Australia
International Journal of Cognitive Therapy (2019) 12:126–145 127

Resulting from theoretical and philosophical, underpinnings of ACT have been a

number of claims attempting to separate it, and at times implying the superiority of its
model, from traditional cognitive-behavioural approaches (e.g. Gaudiano 2011; Hayes
2008; Hayes et al. 2013). These include claims about therapeutic goals and the
establishment of mental health and suggested differences between a treatment focus
on cognitive processes over cognitive content. Despite these suggested differences, a
number of studies comparing the efficacy of CBT and ACT treatment programs have
shown that the two approaches tend to achieve relatively equivalent outcomes (Arch
et al. 2012; Craske et al. 2014a; Forman et al. 2007; Juarascio et al. 2010; Losada et al.
2015).
This paper explores some of the suggested differences in an attempt to identify
common ground and provide further integration of ACT with traditional cognitive-
behavioural theory.

Philosophy and Theory

Human Functioning and Mental Health

According to Hayes and his colleagues (Hayes et al. 1999), the basis of human
functioning giving rise to both functional and dysfunctional human activity, and
thereby mental health, is what they call ‘human language’. According to their descrip-
tion, such human language encompasses all symbolic activity of the mind, whether it is
verbal or non-verbal and is that which provides the basis of meaning. This is consistent
with a constructivist view, whereby individuals interact with their experiences to
construct the meaning in their life, upon which all cognitive-behavioural therapies are
developed (Ellis 2003). Such philosophy recognises the importance of cognitive
processes in human functioning and experience.
In approaching the issue of mental health more directly, Hayes et al. (1999) make the
claim that ACT supplements traditional psychological views which, according to them,
have been based on the assumption of ‘healthy normality’. They note that the impli-
cation of this assumption is that good health is merely presumed to be the absence of
disease or disorder, which they accurately identify as an insufficient description of good
mental health. Good mental health also requires the presence of healthy functioning.
From this suggested assumption of healthy normality, Hayes and his colleagues (Hayes
et al. 1999) then claim that psychology has traditionally presumed that mental health
results in a state of contentment and happiness, with no negative emotions. Conse-
quently, they state that the psychological theory of mental health has therefore been
insufficient in explaining the prevalence of human suffering and distress.
While it is true that psychology has traditionally been more focused on the reduction
and removal of dysfunction and disorder, it is historically naïve to claim that concepts
of positive mental health have been ignored. For example, literature by Freud and
Hubback (1922), Jahoda (1958) and Maslow (1968) stemming back over the past
century, all clearly denote efforts to define what constitutes good mental health.
Furthermore, to suggest that other psychological theories have not acknowledged the
role of ‘healthy negative’ emotions and have espoused a Pollyanna view of life is
facetious. For example, Freud and Hubback (1922) stated that a mentally healthy
128 International Journal of Cognitive Therapy (2019) 12:126–145

individual is able to endure pain, acknowledging it as a part of life and sometimes

necessary for longer term pleasure. More in terms of cognitive-behavioural theory, both
Ellis and Beck acknowledge that experiencing appropriate emotions, not simply
pleasurable emotions, is part of mentally healthy life (Beck and Haigh 2014; Ellis
and Grieger 1986). This can clearly be seen in Ellis’ description of functional and
dysfunctional emotions. In this, Ellis makes the distinction between unhealthy negative
emotions such as depression, guilt and anxiety and healthy negative emotions such as
sadness, regret and concern, further stating that the experience of such healthy negative
emotions is an important part of healthy life (Ellis 2003; Ellis and Grieger 1986).
Returning to Hayes et al.’s (1999) description of human functioning, they highlight
that suffering is common to the human experience. From this, they deduce, in line with
religions and cultural traditions, that normal human processes can be destructive,
coining the term ‘destructive normality’. Again, such a view of psychological func-
tioning is consistent with traditional cognitive-behavioural theory, which has also
drawn on philosophical and religious traditions of mental functioning. For instance,
in his writings on mental health, Ellis (1962) proposes that humans are both innately
rational and innately irrational. Furthermore, Ellis (1987) states that this innate conflict
between rationality and irrationality therefore results in both self-helping and self-
defeating behaviour and makes the concept of achieving perfect mental health impos-
sible. Similarly, Beck (1995), in describing the nature of automatic thought processes,
notes that such thought processes are a natural part of human functioning and that they
can be either functional or dysfunctional. The determination of such functionality is
simply based on the utility of such thoughts.

Assessment of Functionality

With their emerging theories of mental health, Hayes et al. (1999) then took on the task
of developing a paradigm for describing human behaviour, which they termed ‘rela-
tional frame theory’ (RFT). This RFT is based on a philosophy of functional
contextualism, which tries to understand behaviour in a holistic manner, to understand
the context within which it arose and whether it fits with what is called a ‘pragmatic
truth criterion’. In summary, a pragmatic truth criterion allows for the evaluation of
relevant factors contributing to behaviour, within reason, and an evaluation of whether
the behaviour provides pragmatic, or functional, outcomes (Hayes et al. 1999).
With RFT and functional contextualism in mind, Hayes et al. (1999) assert that ACT
provides a radical change from the theoretical and philosophical approaches of other
forms of applied psychology. In trying to separate this theory from traditional CBT
models, ACT theorists (e.g. Gaudiano 2011; Hayes et al. 1999) tend to rely on an
overly simplistic mechanistic account of cognitive-behavioural theory.
In contrast, traditional forms of CBT have been based on logical empiricism. This
approach allows for a combination of reasoning and the empirical measurement of
outcomes. When applied to psychological practice, it covers the rational consideration
of evidence that exists, including ignored evidence, historical data and alternative
explanations (Arch et al. 2012). As such, it similarly allows for the inclusion of all
information potentially relevant to an event, a thought or behaviour. It also allows for
the empirical testing of the outcomes of a person’s behaviour, which can include the
pragmatic assessment of behaviour’s utility.
International Journal of Cognitive Therapy (2019) 12:126–145 129

This logical empiricism can again be seen in writings by both Ellis and Beck. For
instance, when discussing how rationality is determined, Ellis applies what could be
considered to be a pragmatic truth criterion. This is demonstrated in the statements that
there is ‘no absolute, essential view of rationality’ and that ‘rational means self-helping
and irrational means self-defeating’ (pp 19–20, Ellis and MacLaren 1998). This implies
that while thoughts may be functional in many situations, they are not inherently
considered to be functional under all conditions and at all times, rationality is reflected
in logic, empirical support and/or pragmatic utility (Ellis et al. 2010; Ellis and
MacLaren 1998). Similarly, when evaluating the functionality of an automatic thought,
Beck notes such a thought can be assessed for both ‘its validity and/or utility’ (p. 108, J.
S. Beck 1995). Furthermore, second wave cognitive-behavioural theory allows for the
bidirectional relationships between cognitions, emotions and behavioural factors, while
also allowing for the role of social and biological influences (Beck and Haigh 2014;
Ellis 1987, 1994).
Thus, the underlying theory and philosophy behind the application of traditional
forms of CBT and ACT both appear to aim for a holistic understanding of individuals’
functioning and to apply a pragmatic approach to determine whether such functioning
is either functional or dysfunctional. Furthermore, they are all focused on
understanding the impact of context to determine functionality. This is acknowledged
by Hayes (2004) when discussing the importance of goals to therapy and the descrip-
tive contextualism (i.e. a focus on examining how different strands contribute to an
overall story/event) inherent to constructivism. They all demonstrate elements of
rationalism as well. In the case of ACT, this is implicit within the term functional
contextualism, as the context of our existence includes the reality of the world outside
of ourselves. This is more explicit in cognitive-behavioural theory which notes that
mental health is based on an assumption that there is an interaction between a person’s
thoughts and an objective reality (Dobson 2013).
To summarise, the use of overly simplistic mechanistic models to describe second
wave cognitive-behavioural therapies approach to human functioning, as put forth by
those favouring ACT (e.g. Gaudiano 2011; Hayes 2008), can be seen to be quite
reductionistic. Moreover, if wanting to apply such simple models, the same could be
done for ACT, by simply highlighting in isolation a focus on inflexible cognitive
processes as the suggested cause for emotional distress and dysfunction. It would
instead appear that both the traditional and more recently developed cognitive-
behavioural models, all espouse a more nuanced understanding of human functioning,
which appraises the functionality of the components of the human experience (i.e.
cognitive factors, emotions, behaviours) on a pragmatic basis. Furthermore, they all
view the range of dysfunctional and functional responses as being within the range of
normal human experience.

Relational Frame Theory and Rule Governance

To explain human behaviour, including psychological functioning, Hayes and his

colleagues (Hayes et al. 1999) return to Skinner’s models of ‘contingency-shaped
behaviour’ and ‘rule-governed behaviour’. Recognising the adaptive benefits of
contingency-shaped behaviour, to learn from trial and error, they focus more on rule-
governed behaviour. Here, they identify some basic adaptive benefits of such
130 International Journal of Cognitive Therapy (2019) 12:126–145

behaviour, but also identify that less advanced forms of rule governance can become
insensitive to context and change, and thereby less functional. Based on their research
into rule-governed language, Hayes and his colleagues come to the point of stating that
such verbal events control behaviour as these rules tend ‘to become relatively insensi-
tive to changes in the environment that are not contacted by or described in a rule itself’
(Hayes et al. 1999, p. 28).
Such rules are of course a reflection of meanings and associations that the individual
has developed and is thereby referred to as verbal language. Three forms of such
language discussed as having the potential to become problematic are ‘pliance’,
‘tracking’ and ‘augmenting’. Pliance is a form of rule governance where a verbal rule
is followed due to the history of socially mediated consequences between the rule and
the individual’s behaviour (e.g. a child responding to a parents request based on a
history of pleasing or displeasing the parent; Hayes et al. 1999; Zettle and Hayes 1982).
Tracking, on the other hand, is rule-governed behaviour based on the learnt history of
associations between a rule and the natural contingencies (e.g. use an umbrella when it
is raining or you will get wet; Hayes et al. 1999; Zettle and Hayes 1982). Tracking can
still relate to natural social consequences however (e.g. being mean to others means
they will not like you). Augmenting, instead of specifying consequences to a rule, is a
rule-governed behaviour that increases the value of contingencies specified by a rule
(e.g. would not some chocolate be good right now, Hayes et al. 1999; Zettle and Hayes
1982).
These forms of rule governance are identified as giving rise to a number of
problematic processes, as they are rigid and inflexible (Hayes et al. 1999). For instance,
they can give rise to rule-governed behaviour. An example of this would be the rule ‘I
must always put others first’, which will lead to a lack of assertiveness that inhibits the
individual’s ability to achieve goals and to protect themselves from others taking
advantage of them. Other examples include the development of self-fulfilling prophe-
cies and the development of negative biases. For example, a belief that ‘I am worthless’
can contribute to action that reinforces such a belief and can result in distortion of
events, such as positive feedback, to reinforce it. Rules can also be inaccurate and set
up unhelpful relationships which inhibit the person from developing an adaptive
response. For example, ‘others must apologise for me to let go of my anger’. They
can also set up self-reinforcing loops, (e.g. ‘I must not get anxious’). Ultimately, Hayes
and his colleagues (Hayes 2004; Hayes et al., 1999) came to conclude from their study
of rule governance that such verbal behaviour gives rise to psychological inflexibility,
creating difficulties with acceptance and through that psychological distress.
Such an understanding of human psychological distress, with a focus on rigid
language, also known as cognitions, is not new to the cognitive behavioural framework.
In fact, it has always been a central premise. It is reflected in Ellis’ model of REBT with
his focus on ‘demandingness’ and within Beck’s model of CT under the title ‘condi-
tional assumptions’.
Within the REBT model, Ellis (1962) discussed that behind people’s dysfunctional
thoughts and beliefs are irrational demands that are represented by absolutisitic dogmatic
musts and shoulds. This built on Horney’s (1950) earlier work on the ‘tyranny of shoulds’.
Furthermore, he suggested that in response to these demands, people would develop rigid
and inflexible behavioural patterns that are themselves dysfunctional, lacking practical
utility for the individual. Ellis theorised that these demands resulted in difficulty with
International Journal of Cognitive Therapy (2019) 12:126–145 131

acceptance of the self, others and life; these included catastrophic interpretations of events,
low frustration tolerance and deprecating evaluations (Ellis 2003).
In relation to CT, Beck (1976) noted the role of ‘self-coercive language’ in his early
studies of depressed patients and similarly acknowledged the earlier work by Horney
(1950). To describe these, he developed the notion of conditional assumptions. He
describes these as the various rules, assumptions or attitudes that a person holds and
directs towards themselves, others and/or the world in general. He further described
them as being rigid, absolutistic, overgeneralised and over inclusive. Beck stated that
these conditional assumptions often took the form of ‘if….then….’ and
‘unless….then….’ statements, while rules for living were presented in ‘must’, ‘have
to’, ‘ought to’ and ‘should’ statements (Beck and Haigh 2014). Beck related these
conditional assumptions to three broad domains, being acceptance, competence and
control. They were described as being intimately linked with core beliefs and that their
violation led to negative cognitive distortions and biases that are accepted as truth and
contribute to disturb emotions and behaviours.
Thus, it can be seen that all three of these models place a focus on rigid cognitive
beliefs. Whether these rigid cognitions are labelled as ‘rule governance’, ‘demands’ or
‘conditional assumptions’, they are given importance in the generation of further
dysfunctional cognitions, dysfunctional emotions and dysfunctional behaviours. The
role of these cognitions in contributing to distress and dysfunction is also consistent
with appraisal theory and research from cognitive neuroscience (see for reviews Hyland
and Boduszek 2012; Szentagotai et al. 2005).

Psychopathology

As can be seen within the discussion on RFT and rule governance, ACT’s approach to
mental health problems is based on a stoic philosophy. Stoicism is a philosophy that
posits that humans are best to accept that they cannot control everything in life, but that
we can control our attitude towards what happens around us. Furthermore, it espouses
the value of knowledge and logic and that a virtuous life is the highest good (Hazlitt
and Hazlitt 1984; Oakley and Freeman 2009). This philosophy is the basis of all forms
of cognitive-behavioural therapy. Where ACT claims to depart from more traditional
forms of CBT, based on its description of functional contextualism, is that the primary
source of psychopathology is said not to be the form or content of cognitions but the
contexts that lead this cognitive content to inappropriately, or excessively, regulate
human action (Hayes et al. 1999). That is, it is how the individual relates to such
cognitions, not the content of the cognitions that is said to be important and to give rise
to dysfunctional cognitive processes according to ACT (Fletcher and Hayes 2005;
Hayes 2004; Hayes et al. 1999). In particular, this is suggested to give rise to
pathological processes of ‘cognitive fusion’, and through that, experiential avoidance.
Thus, they state that it is not that thoughts are wrong in themselves that causes
distress, it is the context in which the thoughts occur that gives rise to perceptions that
such thoughts are either ‘good’ or ‘bad’. This can then lead the individual to react to
thoughts perceived to be ‘bad’ in ways designed to minimise them, but these reactions
instead lead to internal struggles and psychopathology (Hayes et al. 1999). This is
based on the idea that all conscious efforts to deliberately control thoughts and feelings
are ineffective forms of rule governance that trap the individual.
132 International Journal of Cognitive Therapy (2019) 12:126–145

The first form, cognitive fusion results in over associations whereby a thought
becomes associated, or ‘fused’, with other thoughts, feelings and/or behaviours. Such
a process results in dysfunctional associations, overgeneralisations and inappropriate
labels and evaluations that create distress (Hayes et al. 1999). For example, a person
who thinks ‘I’m an idiot’ and feels depressed may have fused their perception of
themselves with reality and overgeneralised a perception of their behaviour to be a
global reflection of their worth. Similarly, thoughts about anxiety-provoking situations
can become ‘fused’ with an emotional response of anxiety, so merely thinking about the
situation can trigger the anxiety.
Such a process is subsequently suggested to give rise to experiential avoidance,
whereby the individual tries to eliminate the experience of unpleasant internal events
(e.g. thoughts, memories, bodily sensations and feelings). This is then suggested to feed
further cognitive fusion in humans, as it becomes aversive to think about aversive
things (Hayes et al. 1999). Such efforts to control these internal events by suppressing
them have a paradoxical effect, however, increasing dysfunction in the longer term
(Hayes et al. 2013).
This view of psychopathology is consistent with that proposed by other cognitive-
behavioural models. These models address such issues both implicitly and explicitly.
With regard to the arguments about functional contextualism and how individuals relate
to their cognitions, this has always been a focus of cognitive-behavioural models. That
is, cognitive-behavioural models implicitly require the individual to have a level of
belief in dysfunctional cognitions for them to drive maladaptive processes, whereas if
the person views such cognitions as a spurious mental event, they will not drive
dysfunction. This can be observed in writings by Beck and Freeman (1990), where
they note that it is the intensity to which a dysfunctional belief is held that influences
the level of dysfunction it will promote. Similarly, it can be seen in Ellis’ writings on
irrational beliefs (1994).
This cognitive model of psychological dysfunction has achieved consistent support
for a range of psychologically dysfunctional factors at both clinical and sub-clinical
levels (for example, see de Graaf et al. 2009; Deffenbacher et al. 2000; Gagnon et al.
2013; Goldfried and Sobocinski 1975; Himle et al. 1989; Oltean and David 2018;
Taylor et al. 2010; Vîslǎ et al. 2016). It is also consistent with Gross’ emotion
processing theory (Ford and Gross 2018; Gross 1998).
The focus on beliefs brings with it implicit assumptions about the function of
cognition that empower it to promote emotive and behavioural responses (e.g. that
the thought is a statement of fact), which make it more than a fleeting mental event.
Furthermore, the context of dysfunctional beliefs is given importance as well. This
is highlighted by the fact that cognitive models of disturbance only focus on
dysfunctional cognitions in the context of further dysfunction, be that emotional
or behavioural dysfunction. They do not focus on dysfunctional cognitions that
exist in isolation. For instance, a situation where a person has a self-deprecating
thought and may make self-deprecating comments in a humorous context would not
typically be taken as a sign of psychopathology. If the self-deprecating thought is
instead experienced in relation to a depressive emotional reaction, this would
instead be considered a form of psychopathology.
The more explicit focus on the relationship to internal experiences is shown in the
application of cognitive-behavioural models to secondary processes. This includes
International Journal of Cognitive Therapy (2019) 12:126–145 133

models of cognitive and emotional responses to both thoughts and emotions. Ellis in
particular emphasised the importance of secondary processes involving a lack of
acceptance for imperfect internal experiences as being a maintaining factor of emo-
tional distress (Ellis 1987, 1994). This can include times when individuals get de-
pressed about being depressed, perceiving themselves as abnormal for such emotional
experiences (Ellis 1987), or when they get anxious about being anxious, triggering
panic attacks (Clark 1986), or become anxious in response to an intrusive thought, as
demonstrated by cognitive models of OCD (Myers and Wells 2005) or try to avoid
memories of traumatic events (Ehlers and Clark 2000). More recently, the focus on
meta-cognitions has been highlighted by others as well (e.g. K. S. Dobson 2013; Wells
2009).
In terms of the concept of cognitive fusion, this overlaps with cognitive-behavioural
theory focusing on people’s tendencies to apply overgeneralisations, resulting in
negative labelling and evaluations (Beck 1995). All of these terms refer to the process
of over-identifying and overgeneralising an event. This is demonstrated when an
individual fails at a task and evaluates themselves as a ‘failure’. In such circumstance,
the individual has overgeneralised failing at a specific task, or even a series of tasks, to
be a true representation of all that they are. Such overgeneralisation of judgements has
been found to be a contributor to psychological dysfunction relating to a range of
disorders, including depressive disorders, eating disorders and borderline personality
disorder (Thew et al. 2017; van den Heuvel et al. 2012), while overgeneralisation and
associative learning of threat has been associated with anxiety disorders (Lissek and
Grillon 2010; Pittig et al. 2018).
Again, the importance of avoidance of experiences, both in terms of internal and
external experiences, has long been recognised in cognitive-behavioural models. Re-
garding the avoidance of external experiences, this is a key component of even the
simplest of anxiety disorders (e.g. specific phobias), whereby the individual avoids the
external cues relevant to their fear. The avoidance of internal experiences is often
included as a key mechanism in models of many other anxiety-related disorders. This
includes the model of panic attacks, where the individual tries to avoid the experience
of somatic sensations (Clark 1986), posttraumatic stress disorder, where the individual
tries to avoid memories of their traumatic events (Ehlers and Clark 2000) and
obsessive-compulsive disorder, where the individual tries to avoid experiencing intru-
sive thoughts (Myers and Wells 2005). Dobson and Dobson (2018) have also highlight-
ed the importance of identifying cognitive, emotional and behavioural avoidance in
formulating cognitive-behavioural conceptualisations of clients presenting difficulties.
Thus, while approaching psychopathology from a different lens, ACT theory appears to
be consistent with that of traditional cognitive-behavioural theory.

Application to Psychological Interventions

The discussion of suggested differences between ACT and traditional forms of CBT
has been focused primarily upon theoretical and philosophical issues (Hayes 2008;
Herbert and Forman 2013; Hofmann and Hayes 2018; Hofmann et al. 2010). With
regard to the practice of these different therapy models, there is considerable overlap on
how they approach the therapeutic relationship and in the techniques they apply. For
134 International Journal of Cognitive Therapy (2019) 12:126–145

example, this can be seen in their collaborative approaches to treatment, the use of
behavioural goal setting and exposure interventions, the use of attention training
exercises and the use of questioning techniques for insight development and for
addressing the functionality of cognitions and cognitive processes (Ellis 2005;
Gaudiano 2011; Harley 2015; Hofmann and Hayes 2018). The key difference discussed
in relation to therapeutic techniques has been in relation to the underlying mechanisms
through which these strategies make a change, in particular, the focus on suggested
differences between the change to cognitive content and to cognitive processes (Hayes
2008; Herbert and Forman 2013). This has also led to the application of different
techniques to address these cognitive factors directly as well (e.g. cognitive
restructuring vs acceptance techniques). These issues are discussed below.

Acceptance vs Change

In response to the ACT conceptualisation of dysfunction, Hayes and his colleagues

(Hayes 2004; Hayes et al. 1999) criticised the existing approaches to psychotherapy.
They describe the first and second wave behavioural therapies as being purely focused
on first-order change (Hayes 2004). That is, he perceived them to address problems
directly (i.e. focus on behaviour to address behavioural problems, focus on cognitions
to address cognitive problems and to focus on emotions to address emotional prob-
lems). This focus on first-order change was suggested to be problematic, increasing
suffering, particularly in those with the most distress (Hayes et al. 1999). On this basis,
a focus on cognitive interventions to directly address problematic internal experiences
was eschewed (Hayes 2008; Hayes et al. 1999). In light of this, a model of change
focused on acceptance and valued action was set out. The goal of which is to teach
clients how to be good at managing their emotions, rather than teaching clients how to
feel good.
The focus on acceptance was put forth as a way of changing the function, or how the
individual related to thoughts, feelings and behaviours. Hence, it is particularly focused
on internal experiences and was put forth as an adaptive alternative to experiential
avoidance (Hayes et al. 1999). The development of acceptance is not suggested to be an
end in itself, but is a method for increasing psychological flexibility, thereby reducing
rule governance and the inhibitory influence of distressing thoughts and feelings upon
effective living (Fletcher and Hayes 2005). Overt behaviour change is then a focus to
increase valued behaviours in dealing with the external world. In this way, ACT was
suggested to effectively balance the focus on acceptance- and change-focused strategies
(Hayes et al. 1999).
The description of change focus put forward by Hayes, and the basis upon which he
separates ACT from earlier forms of CBT, appears to be based again on an
oversimplified view of cognitive-behavioural models. That is, CBT is not based on a
philosophy of first-order change. While earlier behavioural models may have taken a
first-order approach to change (i.e. changing behaviour for the sake of changing
behaviour), cognitive-behavioural models do not propose a cognitive change for the
sake of cognitive change. They are focused on second-order change (J. S. Beck 1995;
Ellis 1994). Again, this is a way in which cognitive-behavioural models pay attention to
the context of cognition. The focus of such cognitive change is to enhance functionality
across cognitive, emotional and behavioural domains. This also allows for the
International Journal of Cognitive Therapy (2019) 12:126–145 135

application of ‘indirect’ methods of cognitive change (e.g. using exposure to change

perceptions of threat; Beck and Haigh 2014). It also seeks to teach a second-order
philosophy of scientific empiricism to one’s experiences, to encourage flexibility and to
enable for a pragmatic evaluation of thoughts, feelings and behaviours. This is to break
down rigid systems through which individuals had previously approached their life
(Ellis 2003).
More recent advances in cognitive-behavioural theory tying cognitive change to
brain functioning add another layer to this as well. For instance, literature has demon-
strated that cognitive reappraisal strategies activate parts of the prefrontal cortex to
downregulate activation of other parts of the brain involved in emotional distress (for a
review, see Hofmann et al. 2013).
The efforts by ACT to avoid ‘direct’ cognitive-change techniques (i.e. cognitive
restructuring/ disputing) would also appear to be somewhat unfounded and inconsistent
with their own RFT. Firstly, let us return to Hayes et al.’s (1999) discussion of
language, where they aptly note that language is the source of both positive human
achievements and negative achievements, which can be extended to the achievement of
functional experiences. While Hayes et al. (1999) then focus on the role of rule
governance and rigid language patterns in distress, they neglect to return to the use
of language for positive outcomes, instead of trying to eschew all use of language. With
language described as being all symbolic activity of the human mind, whether that is
verbal, images or other, it is impossible to escape the use of language, as without that
symbolic meaning, any interaction would become nonsensical. Furthermore, for a
message of acceptance about one’s internal experiences to effect change for an indi-
vidual, it is a relatively safe assumption to presume they held beliefs that such
experiences were unacceptable in the first place (e.g. ‘I shouldn’t feel depressed’).
Unlike traditional CBT approaches, the ACT approach to therapy just does not focus on
identifying these beliefs before addressing them. Thus, while ACT may utilise ‘indi-
rect’ communication strategies (e.g. metaphors) for addressing a problem, these are still
based in language. Therefore, ‘acceptance’ strategies can be described as an indirect
form of cognitive restructuring. This view is consistent with previous theoretical
discussions (David and Hofmann 2013; Ellis 2005).
The second point of difference that has been raised in the literature with regard to
acceptance and cognitive restructuring strategies has been in regard to their temporal
relationship to a distressing event. That is, there has been a debate about whether such
strategies are precedent or antecedent interventions for a problem (e.g. Hofmann and
Asmundson 2008). Such discussion appears to at times confuse the focus of these
interventions. In these discussions, acceptance interventions are typically described as
being antecedent (Hofmann and Asmundson 2008). Such a distinction is made with
regard to their relationship to primary events (i.e. external events). However, accep-
tance interventions are generally focused on limiting secondary distress. If then they are
considered in relation to secondary events, or internal experiences, they could likewise
be considered to be precedent interventions (i.e. preventative of secondary distress).
In a similar manner, cognitive restructuring interventions can be applied to primary
and secondary events, so depending on the point of consideration, could equally be
considered precedent or antecedent. Herbert and Forman (2013) also cite that cognitive
restructuring techniques can be applied after an emotional event is activated, as a way
of managing the emotion, which would also be an antecedent use of the technique.
136 International Journal of Cognitive Therapy (2019) 12:126–145

Returning to ACTs avoidance of direct cognitive strategies, the discussion around

the supposed sole focus on ‘acceptance’ tends not to highlight the inherent paradox of
this approach. That is that working on acceptance is change. Conversely, cognitive
change strategies put forward by traditional cognitive-behavioural approaches can be
described as efforts at change for the purpose of acceptance. Acceptance and the
reduction of conditional assumptions (CT) and demands (REBT) are the key focus of
cognitive interventions (J. S. Beck 1995; Ellis 1994). In line with this, it can be argued
that traditional cognitive models are a study of the different types of language and
promote the use of more functional language over rule-governed language. This can be
seen in Ellis’ discussion of demand language (e.g. shoulds, musts, needs) against
preferential language (e.g. wants, likes, prefer), which are matched with a focus on
acceptance (Ellis 1987, 2003). Thus, ACTs acceptance strategies can be described as a
change strategy, and direct cognitive strategies can be described as acceptance
strategies.
Research by Cristea et al. (2013) supported this overlap between ACT accep-
tance strategies and the REBT focus on disputing irrational beliefs. They found that
there was moderate to large overlap in the variance explained by these techniques,
but there was also some unique residual variance for each of the techniques. This
was explained by the ability of these techniques to address experiential avoidance
and rigidity (Cristea et al. 2013).
Perhaps more surprisingly, Hayes and colleagues (Hayes 2008; Hayes et al. 1999)
note that cognitive restructuring can be helpful. However, they choose to not utilise
such strategies, worrying about the potential for such strategies to reinforce negative
processes (i.e. people will learn that they should not should on themselves). This
concern is consistent with traditional cognitive-behavioural theory, as it is a reinforce-
ment of unhelpful thinking styles. It is not however how cognitive-behavioural theory
is applied. In line with the discussion above, an adaptive reframe of the rigid thought ‘I
shouldn’t fail, and I’m worthless if I do’ would involve the use of flexible, preferential
language and may become, ‘I’d prefer not to fail, but even if I do I am still an
acceptable person’. So, while traditional models would focus on this issue and try to
deal with it directly, ACT appears to have developed an aversion to using direct
cognitive strategies all together (Ellis 2003). This appears to be a demonstration of
experiential avoidance and violates that pragmatic truth criterion of ACT itself (i.e. it is
hard to do what works when one must avoid it). Due to their concern, they conse-
quently ignore the ever-growing literature that demonstrates direct cognitive interven-
tions are helpful for many people (A. T. Beck and Haigh 2014; Butler et al. 2006). It
also ignores the alternative possibility that indirect strategies may be too vague or
convoluted for some individuals, which could reinforce negative processes in other
ways (e.g. ‘my psychologist doesn’t get me and can’t help me, no one can’, or ‘I don’t
get it, I’m stupid’). Thus, there are potential risks with both direct and indirect methods.
To summarise, there is theoretical and empirical evidence to suggest that accep-
tance and cognitive restructuring interventions largely target the same processes,
but there may be some unique value to each in their own right. Hence, restricting
oneself from using one type of intervention is unnecessarily limiting. Freedom to
use both types of interventions allows for greater flexibility, promoting more
functional outcomes in contexts where one type of strategy may not be suited to a
particular individual.
International Journal of Cognitive Therapy (2019) 12:126–145 137

Cognitive Defusion, Distancing and Labelling

Cognitive defusion techniques are said to be able to address issues relating to the over-
identification with language. Such over-identification is suggested to contribute to
suffering, to limit understanding of personal history, to interfere with the ability to
objectively experience life and to fuse the person with their internal experiences (Hayes
et al. 1999). They are designed to change the function of internal experiences by
changing the context within which they are experienced without ‘attacking’ them
directly (Fletcher and Hayes 2005). Through these strategies, the importance, believ-
ability and meaning given to the internal experience are said to be changed. They are
also suggested to help people understand the temporary nature of such internal events
and to encourage contact with the present moment (Fletcher and Hayes 2005).
This cognitive fusion is noted as being prominent in people’s attachments to their
reasoning (i.e. ‘because I think it, it is true’), and to the conceptualisation of self (Hayes
et al. 1999). Such fusion therefore makes it difficult for people to objectively assess
their reason giving in terms of its functionality and leads to problematic
conceptualisations of the self. These conceptualisations can be problematic as they
are unacceptable (e.g. ‘I’m a failure’ and/or imply a lack of capacity for change, e.g.
‘I’m a depressed person’), whereby the unwanted experiences become a part of the
person’s identity, rather than a more transient experience.
Again, the theory behind these interventions is consistent with traditional CBT. A
tendency to over-identify with a particular event or experience that results in evalua-
tions that block acceptance, contributing to labelling has long been a focus of cognitive
interventions (J. S. Beck 1995; Ellis 1994). In fact, ‘cognitive distancing’, the process
of gaining distance from thoughts, allowing for greater objectivity, has long been
considered a necessary step of cognitive restructuring interventions, allowing the
individual to distinguish between their thoughts and reality (Hofmann et al. 2010).
With regard to the use of cognitive defusion with reason giving, ACT theory focuses
on the role of simplistic reasons for experiences and how these can inhibit functioning
(e.g. ‘I hit them because I was angry’; Hayes et al. 1999). The difference between this
and traditional cognitive-behavioural theory is again based on ACTs tendency to ignore
the development of functional language, noting that overly simplistic reasons for events
can be problematic. Despite this, ACT does include the use of pragmatic challenges to
address unhelpful reasons, for example ‘And does that description of your past help
you to move ahead?’ (p. 164, Hayes et al. 1999).
Cognitive-behavioural approaches are not restricted from directly managing such
issues. Strategies can include psycho-education about the complexity of human behav-
iour, helping the individual to develop a nuanced understanding of human behaviour,
not only appreciating the role of present thoughts, feelings and behaviours, but also
allowing for the understanding of how the individuals history and biology contribute to
these, and the use of challenges to the logical and pragmatic implications of overly
simplistic reasons (J. S. Beck 1995; Ellis 1994). It is also worth noting again that the
underlying philosophy of cognitive-behavioural theory encourages a rational empirical
approach to life, allowing for the evolution of these pragmatic ‘reasons’ when further
information is revealed. Thus, it can be seen that direct cognitive strategies can help a
person to develop more functional reasons, to develop healthy scepticism to their own
thoughts and thereby become less ‘fused’ with them.
138 International Journal of Cognitive Therapy (2019) 12:126–145

In a similar manner, traditional cognitive-behavioural models implement direct

cognitive strategies to help address dysfunctional evaluations and labels. For instance,
disputing techniques could be implemented to help break down the over association
with the evaluation ‘I am a failure’. This would involve helping the individual to see
that a single failure or even a series of failures is an inadequate basis upon which a
human can be evaluated. That is, while a particular act can be labelled, a person cannot
be. In a similar manner, empirical challenges may help the person to see that they are
overgeneralising from one failure and ignoring successes in their life.
The act of distancing from emotional experiences (e.g. ‘I notice I am feeling
anxious’) can also be likened to a traditional CBT strategy of affect labelling. This is
a strategy whereby the individual puts language to their emotional experiences. The
strategy has been shown to have implicit benefits in emotion regulation, demonstrating
reductions in emotional distress similar to those arising from reappraisal strategies,
activating neural mechanisms within the frontal cortex to downregulate the emotional
processes (Burklund et al. 2014; Lieberman et al. 2011; Torre and Lieberman 2018).

Experiential Avoidance: Willingness vs Control

Hayes and his colleagues (Hayes et al. 1999) state that experiential avoidance is the
result of control strategies employed by individual’s to prevent the occurrence of
unpleasant private experiences (i.e. thoughts and emotions). As a result, they conclude
that ‘control is the problem’, and try to distinguish themselves from other forms of
psychological therapy. They further suggest that other forms of psychological therapy
are problematic as they encourage control in a manner that will simply reinforce
experiential avoidance, highlighting the use of ‘emotional control’ strategies as a
particular example of this. The solution to this, ACT suggests, is in cultivating
acceptance in the form of a ‘willingness’ to experience unpleasant private experiences
(Hayes et al. 1999).
This discussion may highlight a problem with the use of language that has histor-
ically been used to describe some cognitive-behavioural interventions. For example, the
use of terminology such as ‘emotional control strategies’ does appear to be imprecise.
Cognitive-behavioural strategies instead attempt to focus on utilising the ability to
control aspects of human functioning that is directly under the control of the conscious
mind. This includes factors such as attention control, behavioural choices and deliber-
ate reasoning (A. T. Beck and Haigh 2014). It does not involve direct control over
emotions and automatic thought processes. However, the application of the factors
under conscious control will influence reinforcement strategies that work to upregulate
or downregulate the unconscious processes over time (Beck and Haigh 2014). Thus,
efforts to directly control emotions would be problematic, as it would be trying to
directly control aspects of psychological functioning that people do not have direct
control over.
Hayes et al.’s (1999) issue with the use of control strategies, or more specifically
dysfunctional control strategies, is that they are geared towards eliminating the expe-
rience of negative private experiences. This is consistent with cognitive-behavioural
theory. An effort to eliminate such experiences completely is underpinned by a
perfectionistic demand regarding human functioning. It has been noted that such beliefs
can lead to awfulising of emotional experiences, negative self-evaluations, negative
International Journal of Cognitive Therapy (2019) 12:126–145 139

beliefs about one’s ability to cope with such experiences and a lack of self-acceptance
(Beck et al. 1992; Ellis 1987; Myers and Wells 2005). It is also unrealistic as the
experience of these negative private experiences is influenced by processes that
evolved for adaptive purposes, often linked to survival and efficiency (Beck and
Bredemeier 2016; Beck and Haigh 2014). Traditional approaches to cognitive-
behavioural therapy have historically helped to show people that such processes
exacerbate their distress and to help break down such reactions (Ellis 2003). This
includes the development of acceptance for negative private experiences and of the self
for having them. It can also include education that such reactions are normal, but
maladaptive as they are inappropriate to the stimulus that triggers them, and promote
actions that are inappropriate to the context in which they occur.
This is to promote a devaluing of such negative private experiences, and ultimately a
focus on developing more adaptive reactions (Beck and Haigh 2014; Ellis 1994). This
includes both the development of more adaptive cognitive processes and behavioural
choices. Such a focus, like in ACT, results in the promotion of a willingness to accept
thoughts and emotions that were triggered by automatic processes that are out of direct
conscious control and to be willing to put such automatic thoughts to the side and
persist with adaptive behaviours despite unpleasant emotional experiences. Unfortu-
nately, this focus on secondary processes may have been somewhat under emphasised
in education and research on cognitive-behavioural therapy. Subsequently, some au-
thors have mistakenly perceived that a shift to focusing on meta-cognitions has only
been a recent development in cognitive-behavioural theory (Dobson 2013).
An acceptance of emotional discomfort while engaging in behavioural interventions,
with exposure interventions being a primary example, has long been understood to be a
key component of the effective application of such techniques. This is where the
individual controls their behaviour so that they willingly come into contact with feared
stimuli and then experience a subsequent decline in anxiety (Ougrin 2011) or gain
inhibitory learning (Craske et al. 2014b). The application of these exposure interven-
tions has now demonstrated a long history in helping to effectively treat anxiety-related
disorders (for reviews, see Craske et al. 2014b; Foa and McLean 2016; Ougrin 2011).

Values in ACT vs CBT

ACT claims to be somewhat unique in that it does not focus on symptom reduction as a
goal of therapy but rather focuses on the development of a valued life. In contrast,
Hayes has criticised traditional forms of CBT as being too symptom focused (Hayes
2004). In ACT, values are said to provide a stable approach for directing behaviour in
life. Values are differentiated from goals, with goals being defined as objects or events
to attain, whereas values are said to provide a direction that integrates ongoing patterns
of purposeful action (Fletcher and Hayes 2005; Hayes et al. 1999). Furthermore, in
committing to act on values, people are said to choose life directions that are mean-
ingful, while also disengaging from problematic processes, including avoidance, social
compliance and fusion (Fletcher and Hayes 2005).
Again, here the issue is not that a focus on value-based action is unhelpful, it is with
the lack of recognition that such a focus overlaps with traditional approaches to CBT.
Ellis highlights that REBT has an existential focus, stating that to function well humans
require meaning and purpose in life and that it advocates that people create and work on
140 International Journal of Cognitive Therapy (2019) 12:126–145

building purpose and meaning (Ellis 2003, 2005). In line with this, he strongly
advocated for disputation to promote individuals to develop a healthy philosophy
towards life that encourages self-fulfilment and self-actualisation. The use of pros
and cons lists, such as that used in CT models for the treatment for substance use
(Beck et al. 1993), also demonstrate a focus on values. In these exercises, the various
pros and cons are also weighted for their importance to the individual, thereby
including a focus on underlying values. These strategies can then lead to behavioural
goals that are contrary to dysfunctional emotional drives, which are consistent with
ACT’s focus on committed action.

Summary

This section has highlighted that while ACT and other cognitive-behavioural models of
dysfunction may use differing language to describe dysfunctional psychological pro-
cesses, the underlying principles of these models are largely the same. This is not
surprising, as they both attempt to explain the same psychological processes. Further-
more, while they may suggest the use of different interventions to address these
problematic processes, the mechanisms, upon which interventions are based, are also
consistent across the various approaches. This is consistent with the statements by
Hofmann and Hayes (2018). They suggest that different cognitive-behavioural strate-
gies may target the same underlying cognitive processes (e.g. cognitive restructuring
and cognitive defusion/distancing may both target cognitive flexibility). Historically,
and somewhat surprisingly, it seems that proponents of ACT are less flexible and less
pragmatic in their advocacy of effective interventions.

Concluding Remarks

There has been much debate about whether ACT represents a paradigm shift in
addressing human functioning (Gaudiano 2011; Hofmann 2008; Hofmann and
Asmundson 2008; Hofmann et al. 2010). Hayes and his colleagues have argued that
it provides an approach that is sensitive to the context and function of psychological
phenomena, which is distinct from the ‘second wave’ cognitive-behavioural therapies
(Hayes 2004). While others have noted that at a technological level, differences are
quite limited; there has been an ongoing discussion of possible theoretical and philo-
sophical differences (Herbert and Forman 2013).
This article has examined the underlying theory, delving into the constructs
discussed in the various cognitive-behavioural models, and their underlying philoso-
phies in an attempt to highlight the commonalities between them. This has led to the
conclusion that the ‘second wave’ cognitive-behavioural therapies and ACT are largely
underpinned by the same constructs. There are differences in the language used to
describe these, which have been influenced by the theoretical backgrounds of each, and
perhaps the idiosyncrasies of those that developed each of the approaches. Other
differences can be noted in the emphases placed on the discussions within each
approach. What one model deals with directly, the other tends to deal with indirectly.
For instance, traditional CBT models focus on direct cognitive challenging to
International Journal of Cognitive Therapy (2019) 12:126–145 141

encourage self-acceptance, whereas ACT uses acceptance techniques, which arguably

indirectly challenge dysfunctional cognitions (Ellis 2005). This leads to the conclusion
that they are simply looking at two different sides of the same coin.
Research by Cristea et al. (2013) has supported this notion. They found that there
was considerable overlap between key constructs from REBT and ACT. They also
found that key constructs were related to each other, and ultimately with distress. For
instance, experiential avoidance/psychological inflexibility mediated the relationship
between cognitive constructs of irrationality, unconditional self-acceptance, dysfunc-
tional attitudes and distress. It has similarly been shown by Wild et al. (2017) that while
ACT and REBT approach the process of developing acceptance in differing fashions,
the outcome in terms of the development acceptance and emotional change is much the
same.
The rise of the so-called third wave cognitive-behavioural models, such as ACT, has
perhaps highlighted an issue with the training and the application of ‘second wave’
cognitive-behavioural therapies. It is possible that the focus on secondary processes on
previous training and practice has been neglected to some degree. The focus on
secondary, or internal experiences, has become a key focus in many of the cognitive-
behavioural modalities that have been developed over recent years. This includes
mindfulness-based cognitive therapy (Segal et al. 2002), mindfulness-integrated CBT
(Cayoun 2011) and dialectical behaviour therapy (Dimeff and Linehan 2001), in
addition to ACT. This may reflect that there has been a lack of sensitivity in the
previous training in cognitive-behavioural therapy that failed to emphasise the impor-
tance of secondary process in psychological dysfunction.
A benefit of these newer modalities has been the development of additional inter-
ventions to target cognitive-behavioural mechanisms of change. The ability to approach
the same contributing factors to dysfunction through a variety of interventions better
equips psychologists to help individuals, giving alternatives when there is difficulty
with the application of one.
Despite this, it is still important to recognise the commonalities between these
approaches and to understand the underlying mechanisms of change. All cognitive-
behavioural models work on helping individuals to relate to their cognitions, emotions
and behaviours in healthy ways. While some strategies may focus more on how the
individual relates to the external world, this has implicit implications for how they
relate to their internal world. For instance, cognitive restructuring helps the individual
to step back from their thoughts and to evaluate them on a pragmatic and utilitarian
basis. In a similar manner, mindfulness strategies help the individual to disengage from
their thought processes and become more an observer of such a phenomenon. By doing
this, it is commonly recognised that there are implicit changes to the content of the
thought process, as people identify less with their thoughts and become more objective
on how they think about situations. This once again highlights that while these different
strategies may approach mental health issues in differing ways, they ultimately relate to
the same underlying theory of human functioning.
It would therefore seem more prudent to pull these threads of cognitive-behavioural
theory and practice together, based on their underlying commonalities. This would help
in strengthening the support for the cognitive-behavioural framework and help with the
development of a more cohesive model of human psychological functioning based on
established principles. This is consistent with the aims of the recent collaboration
142 International Journal of Cognitive Therapy (2019) 12:126–145

between Hofmann and Hayes (2018). They argue that CBT, and the field of psychology
more generally, is best served by a move towards process-based therapy. This move
would focus on the development of the field on empirically supported processes and
procedures of change (Hofmann and Hayes 2018). Such an approach would also help
to focus attention on enhancing our understanding of psychological functioning and on
the development of more nuanced and advanced interventions to improve people’s
mental health. It would orient research towards informing upon which psychological
processes contribute to which psychological outcomes, and what procedures are best
for intervening upon these. It would also help to stop the proliferation of ‘new’
modalities that obfuscate the landscape of psychological practice and to stop what
appear at times to be egotistical competitions about whose modality (i.e. idiosyncratic
approach) is best.

Compliance with Ethical Standards

Conflict of Interest James Collard declares that he has no conflict of interest.

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