1 s2.0 S0005789422001022 Main

Journal Pre-proofs
ACT: A Process-Based Therapy in search of a process
Shane McLoughlin, Bryan T. Roche
PII: S0005-7894(22)00102-2
DOI: https://doi.org/10.1016/j.beth.2022.07.010
Reference: BETH 1205
To appear in: Behavior Therapy
Received Date: 21 June 2021

Accepted Date: 28 July 2022
Please cite this article as: S. McLoughlin, B.T. Roche, ACT: A Process-Based Therapy in search of a process,
Behavior Therapy (2022), doi: https://doi.org/10.1016/j.beth.2022.07.010
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover
page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version
will undergo additional copyediting, typesetting and review before it is published in its final form, but we are
providing this version to give early visibility of the article. Please note that, during the production process, errors
may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2022 Published by Elsevier Ltd. on behalf of Association for Behavioral and Cognitive Therapies.
ACT AS A PROCESS-BASED THERAPY 2
Shane McLoughlin1
Bryan T. Roche2
1University of Birmingham
2Maynooth University
Author Note
Corresponding author: Shane McLoughlin ([email protected]). This paper

was an invited article to the special issue of Behavior Therapy critically appraising ACT therapy.
Acknowledgements
The authors would like to thank Dr. Richard May and Paul Watts for their helpful
comments, and several others from the ACT/RFT community for their moral support in
producing this paper.
Abstract
A large array of randomized controlled trials and meta-analyses have determined the efficacy of
Acceptance and Commitment Therapy (ACT). However, determining that ACT works does not
tell us how it works. This is especially important to understand given the current emphasis on
Process-Based Therapy, the promise of which is to identify manipulable causal mediators of
change in psychotherapy, and how their effectiveness is moderated by individual contexts. This
paper outlines four key areas of concern regarding ACT’s status as a Process-Based Therapy.
First, the relationship between ACT and Relational Frame Theory has been widely asserted but
not yet properly substantiated. Second, most of the studies on ACT’s core process of change,
psychological flexibility, have used invalid measures. Third, while lots of research indicates
means by which individuals can be helped to behave consistently with their values, there is
virtually no research on how to help people effectively clarify their values in the first instance, or
indeed, on an iterative basis. Finally, the philosophy underlying ACT permits a-moral
instrumentalism, presenting several ethical challenges. We end by making several
recommendations for coherent methodological, conceptual, and practical progress within ACT
research and therapy.
Keywords: process-based therapy, values, value clarity, relational frame theory, acceptance and
commitment therapy, mechanisms of action

Acceptance and Commitment Therapy (ACT; Hayes et al., 1999) is a third-wave
behavior therapy putatively comprised of multiple components. “Acceptance”, in ACT, refers to
an appreciation of the fact that troublesome thoughts are a normal, unavoidable, and often
necessary part of the human experience. Therefore, it makes sense to acknowledge the presence
of negative thoughts and emotions but try to redirect one’s attention towards what makes life
worthwhile (facilitated using self-compassion, mindfulness etc.). In contrast, Cognitive
Behavioral Therapy (CBT) focuses more on changing maladaptive cognitions and dysfunctional
beliefs (Beck, 1993). “Commitment”, in ACT, refers to the orientation of the individual towards
value-consistent behavior instead of efforts to reduce negative thoughts/emotions. In ACT,
values are not just goals, but rather, “adverb-like, as qualities intrinsic to action that can be
instantiated but not obtained or finished” (Chase et al., 2013, p. 79). In other words, in ACT,
values are more related to moral characteristics (e.g., kindness, integrity) than areas of life (e.g.,
family, relationships) or stuff (e.g., money, holidays) that we value. ACT’s core thesis is that
engaging in value consistent behavior (VCB) subsequently often reduces psychological suffering
as a by-product (see Sonntag et al., 2017).
Process-Based Therapy (PBT) refers to “contextually specific use of evidence-based
processes linked to evidence-based procedures to help solve the problems and promote the
prosperity of particular people” (Hofmann & Hayes, 2019a, p. 38). ACT aspires to be a PBT
(Ong et al., 2020). The PBT approach to psychotherapy has received full book-length treatments
(Hofmann & Hayes, 2020) and articles on the topic have been published in leading clinical
psychology and psychiatry journals (e.g., Hayes et al., 2019; Hofmann & Hayes, 2019b). For this
reason, it seems reasonable to ask; What are the core therapeutic processes and mechanisms of
ACT and what evidence is there to support their status as such? This article considers the
existing evidence-base for the inter- and intra-personal mechanisms of action in ACT, while
attempting to identify opportunities for conceptual and empirical progress. Here, we adopt the
following definition of mechanism as “the steps or processes through which therapy (or some
independent variable) actually unfolds and produces the change” (Kazdin, 2007, p. 3).
Functional Links Between Relational Frame Theory and ACT: Asserted but Not
Substantiated
Relational Frame Theory (RFT; Hayes et al., 2001) is a behavior-analytic theory of
language and cognition that was largely developed by one of the co-founders of ACT. In RFT,
language and cognition are considered to be expressions of an underlying ability to relate stimuli
based on symbolic properties (e.g., A is more than B and C is less than B), with the
generativity/novelty of language and cognition being explained by the ability to derive novel
relations (e.g., A is more than C). While it is not relevant to the current paper to outline every
facet of RFT itself, McLoughlin et al. (2020) provide a relatively unbiased discussion of its
promise, outlining the theory itself more fully for interested readers. For purposes of the present
article, what is important to appreciate is that ACT was co-developed alongside RFT, by many of
the same researchers, and that there is a prevailing idea that ACT is one form of applied RFT
(see Hayes et al., 2006) given that language (putatively explained by RFT) is the tool ACT
therapists use to produce change in their clients. This idea has been the subject of book-length
treatments (Törneke, 2010; Villatte et al., 2015), and book chapters (Törneke et al., 2015). Some
RFT researchers have even proposed that it may be desirable, in the interests of achieving
technical precision, for ACT researchers to use RFT-consistent language rather than introducing
natural language (sometimes termed ‘middle level’) terms for concepts within clinical
psychology (e.g., Barnes-Holmes et al., 2018).
Both ACT and RFT are championed by the Association for Contextual Behavioral
Science (ACBS) as essential to its mission and as symbiotically related to each other. A search
on the ACBS website (contextualscience.org) for “Clinical RFT” reveals dozens of hits revealing
the extent to which ACT practitioners support the idea that ACT and RFT are to a large extent
mutually entailed and co-evolving (see also Hayes et al., 2022). However, one important
question here is whether RFT has gained sufficient empirical support as an account of human
language and cognition from the point of view of those outside the field. A second important
question that we will focus on more so, is whether there is sufficient evidence to support a
functional (rather than merely theoretical) relationship between ACT and RFT. Superficially, it
appears that RFT is an empirically supported and well-cited theory (e.g., O’Connor et al., 2017
reported that there were 521 RFT papers from 2009-2016 alone), which could therefore be drawn
upon as a theoretical basis for ACT. Upon closer inspection, O’Connor and colleagues’
assessment of RFT’s empirical standing might be unduly optimistic in several ways. Specifically,
only 55% of the studies they reviewed that included RFT-related search terms were empirical
studies. This renders the RFT literature base alarmingly top-heavy with theory and conceptual
analysis.
Many Empirical RFT Studies are on Implicit Bias
Of the RFT-related papers identified by O’Connor et al. (2017) that were broadly
empirical (N = 288), n = 128 were classed as “other” rather than “RFT”, narrowing down the list
of actual empirical RFT studies further. Dymond and May (2018) argue that the search terms
were too broad even amongst the remaining “empirical RFT” articles (n = 160), with several
clear examples of non-RFT studies (e.g., Miguel et al., 2015 studied analogy from a Skinnerian
perspective) counted as “empirical RFT” studies. 47 of the (something fewer than) 160 empirical
RFT studies involved reports on the use of a single “implicit bias” test called the Implicit
Relational Assessment Procedure (IRAP). The myriad of studies involving the IRAP across a
range of domains (food preference, object preference, cultural preference etc.) do not necessarily
support RFT as a theory; the same experimental procedure was conceptualised within the
cognitive psychology literature and, in terms of producing original data, this method predated the
IRAP (A. P. Gregg, 2007). In this case, as may also be the case in ACT, RFT was not required to
produce any of the ensuing methods and positive findings associated with these methods. In any
case, implicit bias tests, a priori, have no applications within clinical practice with individual
clients. Even if implicit tests did measure a real bias at a group level: (i) their proponents broadly
agree that they are not useful for individual diagnoses (see Jost, 2019) pertinent to
psychotherapy, (ii) they rely on participant compliance to be accurate, and (iii) it would be
unethical to treat a person differently based on anything other than their real-world behavior (cf.
based upon highly variable indirect measures of biases that a client does not even know they are
having, and that may or may not manifest in their everyday behavior).
RFT Findings Cannot Yet Be Generalized
Of course, RFT is arguably a promising theory of language and cognition, especially
given its theoretical congruence with key findings in cognitive science, neuroscience, linguistics,
and other disciplines (see McLoughlin et al., 2020), and it appears to have many potential
clinical applications (see Hayes, Law, et al., 2021). On the other hand, many of these involve
single-subject investigations of symbolic relating behavior implicated in psychopathology or
involve N<10 participants per study (Dymond & Barnes, 1995; May et al., 2017; McLoughlin et
al., 2018; McLoughlin & Stewart, 2017; Steele & Hayes, 1991), or small samples per
independent condition (McHugh et al., 2004; Villatte et al., 2010). Small sample studies like
these have been the bread and butter of high-precision basic behavioral research studies for
decades, allowing for high degrees of control over contingencies governing complex behavior
within the samples selected. However, a researcher with no affiliation to RFT might reasonably
argue that this does not necessarily allow RFT researchers to generalize their findings to the
broader population such that they can make claims about language and cognition writ large,
because they do not involve representative samples of any given population. It follows that
numerous small sample studies, each with non-representative samples, and with varying
procedures and outcome measures, do not easily form a sufficient basis upon which to establish
general principles of language and cognition. In contrast, multiple tests of the same hypothesis,
across laboratories with minimal vested interests, employing the same procedures, would allow
for a relatively an unbiased accumulation of evidence for particular hypotheses.
Replication Issues and Publication Bias
Familiar effect sizes (Cohen’s d, Eta squared etc.) and measures of error (e.g., SEs,
confidence intervals) are often unreported in “single case” basic RFT studies (e.g., Dymond &
Barnes, 1995; May et al., 2017; McLoughlin & Stewart, 2017) as in most other experimental
analyses of similar basic cognitive phenomena (see Corral et al., 2018). Perhaps unsurprisingly,
there has never been a large scale assessment of publication bias and methodological quality of
the literature on RFT’s most fundamental tenets (though see May et al., 2022 for a recent meta-
analysis of one applied RFT intevention). This is arguably important given that RFT is such a
specialist research area in which researchers are likely to have some vested interest (as briefly
mentioned in May et al., 2022) in yielding and promoting positive outcomes. For example,
Context Press publishes books on RFT and ACT and was founded by a co-founder of ACT and
RFT. These concerns about potential sources of bias are reinforced by findings that researcher
allegiances are moderately to strongly associated with effect sizes in tests of CBT treatment
efficacy (Maj, 2008; Munder et al., 2013; Reid et al., 2021). While we would not for a moment
suggest that there is any conscious intent to deceive audiences within the RFT literature, and
while we have a great degree of respect for (and indeed are authors of!) many of the small N
studies that comprise the RFT literature base, the issue of reliance on conceptual extrapolation
from low N studies with no systematic measures of bias cannot be avoided with ease.
There are many conceptual pieces (e.g., Luciano et al., 2021; Törneke et al., 2015) on the
clinical applications of RFT that contain no empirical synthesis of the available evidence base
(e.g., meta-analyses of the effect of specific technique X on specific outcome Y) to provide an
unbiased assessment of the quality of such evidence. In our opinion, this pushes the promise of
an empirically grounded evidence base for ACT methods even further away. For instance, and in
the interest of providing a steel-man argument here to support this case, we might purposively
focus on what is perhaps the cream of Clinical RFT empirical research that both uses a robust
design (as opposed to single-subject designs, discussed above) and has undergone independent
replication by a disinterested party (the only clear exemplar of which we are aware). Specifically,
Sierra et al. (2016) sought to test whether the effectiveness of therapeutic metaphors for
improving pain tolerance could be enhanced by modifying them in accordance with what RFT
would predict to make them more effective. Specifically, in accordance with RFT, matching
physical properties (in this case, temperature) between a metaphor’s content (“imagine
swimming through a cold swamp”) and an aversive task (tolerating pain in a cold pressor task)
should increase perseverance within that task. Moreover, invoking one’s values within the
metaphor (i.e., swimming in the cold swamp towards something of value) should also transform
the aversive task into a valued action, leading to increased perseverance. In a small randomized
controlled trial (RCT), Sierra et al. (2016) reported confirmation of these ACT-related
hypotheses derived from RFT.
This general finding was extended further by the same research group (Criollo et al.
2018), suggesting that this may be a robust effect, and a clear example of how RFT might
augment ACT practice. However, more recently, Pendrous et al. (2020) conducted a pre-
registered replication study of the Sierra et al. (2016) study, which yielded null results. Sierra and
colleagues should be credited with being one of the few teams to attempt to test RFT predictions
in relation to therapeutic outcomes using a relatively robust design. This is precisely the type of
work that is required to build bridges between RFT and ACT. It is entirely possible that this non-
replication could be a Type 2 error. At minimum, however, the Pendrous et al. study shows that
the broader RFT-metaphor effects reported in the original (Sierra et al., 2016) and subsequent
(Criollo et al., 2018) studies are temperamental. To be clinically useful, any intervention effects
must be robust to complex and dynamic treatment environments (i.e., their scope is limited;
Hulbert-Williams et al., 2020).
Summary
It is clear that ACT researchers and practitioners often promulgate the idea that the
empirical robustness of RFT is a unique selling point of ACT, typically referring to the quantity
of studies in the area (see O’Connor et al., 2017). This is exemplified in relation to the discussion
on RFT more broadly. For example, Hayes et al. (2021) say:

“This literature is now quite voluminous and, thus, a challenge to summarize. Our
solution in this paper is to take a small set of examples and to do a more adequate review of
what is known there, while waving a hand at the larger body of work that is available.” (p. 13)
Such “hand-waving”, as these authors put it, may create a powerful narrative if repeated
by people who are sufficiently senior within ACBS. However, it does not present a sufficiently
critical evaluation of the quality of published RFT studies, a critique that extends towards RFT’s
therapeutic relevance. Nonetheless, Clinical RFT is promoted to clinicians in workshops (e.g.,
Barnes-Holmes, 2015; Villatte, 2018, 2021) and books (Törneke et al., 2015; Villatte et al.,
2015) as a well-grounded approach to psychotherapy that harnesses an understanding of basic
processes of language and cognition. However, the burden of proof has not been sufficiently
assumed by RFT/ACT researchers/trainers to show that ACT benefits empirically (not just
conceptually) from the literature base on RFT (see Lilienfeld et al., 2013 on "burden of proof" in
relation to clinical efficacy).
Mismeasurement of the Core Process of ACT
The core process of ACT is claimed to be Psychological Flexibility (PF; Hayes et al.,
2006). More specifically, to assert that PF is the core process of ACT is simultaneously to assert
that PF is a mediational process of change in ACT (e.g., Ciarrochi et al., 2010). Therefore, a
critical analysis of PF is crucial when assessing ACT’s standing as a PBT. PF has been defined
as “the ability to contact the present moment more fully as a conscious human being, and to
change or persist in behavior when doing so serves valued ends” (Hayes et al., 2006, p. 7).
The Hexaflex
PF is said to have six component processes, which are not reflected in the definition
above: present moment awareness, values, committed action, self as context, defusion, and
acceptance (Levin et al., 2012). While there are studies of these individual components and their
role within ACT (see also Hayes et al., 2022), the evidence base for these fitting together within
a global PF model to affect therapeutic outcomes is relatively scant. To claim evidence for this
“Hexaflex” model of PF, we cannot rely on conceptual consensus of ACT practitioners and
researchers alone, as the six-part structure of a latent variable is a psychometric rather than
conceptual claim. With this in mind, those wishing to provide evidence for the Hexaflex might
follow several steps, in order. First, they could develop valid and reliable measures of each of the
six core processes, as all subsequent inferences depend on the quality of these measurement
tools. Part of this would include ensuring that each component can be distinguished from general
distress/negative emotion (i.e., to ensure that we are measuring what we think we are measuring).
Next, they might be included in an exploratory factor analysis, showing each of these six
processes to be distinct (i.e., items from each of the six components should load onto the
expected factors without cross-loading to any significant degree). Next, a hierarchical
confirmatory factor analysis (or structural equation model) in a new sample should show that,
not only are the six processes distinct, but they load onto a superordinate factor we might call
psychological flexibility with acceptable model fit. Having established the factor structure, we
may then have provided evidence for the Hexaflex model of PF. This was broadly achieved
within one psychometric measure of PF (outlined below; also see Landi et al., 2021). However,
this is not the same as showing the six-factor hierarchical model (as opposed to one or two of its
components at a time) to be a critical part of the change process within ACT therapy. To do this,
we would need to show that changes in a given outcome variable within ACT treatment studies
are mediated by changes in this latent PF construct (e.g., using longitudinal structural equation
modelling). Below, we discuss various putative measures of PF, only one of which measures all
six hypothesized components of the Hexaflex.
6500+ Wrong Conclusions?
Lilienfeld and Strother (2020) argued that one of Clinical Psychology’s four sacred cows
is that we can safely rely on the name of a measure to infer its content. For this reason, we must
ask whether we can measure PF as the core ACT process. Thankfully, several researchers have
already sought to do this (see Doorley et al., 2020). The most popular measure of PF upon which
the vast majority of research on ACT processes is based, is the Acceptance and Action
Questionnaire (AAQ; Hayes et al., 2004), and its revised version, the AAQ-II (Bond et al.,
2011). Combined, these two questionnaires have been cited over 6,500 times, at the time of
writing. However, despite these undoubtedly honest attempts to measure PF and test its effects
within ACT, several studies have now suggested that the AAQ-II, in particular, may simply
measure trait negative emotion/neuroticism, or some of its facets like experiential avoidance or
distress (Rochefort et al., 2018; Tyndall et al., 2019; Vaughan-Johnston et al., 2017), or that the
AAQ-II does not generally predict clinical symptoms over and above such factors (see Gloster et
al., 2011).
A relatively recent review (Ong et al., 2019) reveals that there are many variants of the
AAQ, many of which have not been subjected to confirmatory analyses, with very limited tests
of incremental predictive validity. These AAQ variants typically show that context-specific
measures are shown to predict outcomes better than context free measures, a finding that is not
unique to this literature (see Swift & Peterson, 2019). Importantly, this finding does not speak to
the structural properties of PF (i.e., 1. do the items load onto the expected factor structures and
sub-structures? and 2. do related factors such as negative emotionality load onto separate
factors?) or incremental criterion validity (i.e., do those factors differentially predict outcomes of
interest alongside things like negative emotionality) of those AAQ measures, both of which are
important for establishing overall construct validity. The bottom line here, however, is not that
all 6500+ papers citing the AAQ and AAQ-II are necessarily without merit. Rather, it is that
6500+ papers need to be reinterpreted and made sense of in light of the fact that the AAQ and
AAQ-II measured something entirely different to what its adopters supposed it measured. For
example, we could take any given AAQ study and search for instances of “psychological
flexibility” or “PF” in their Method, Results, and Discussion sections, and replace those
instances with “neuroticism” or “negative emotion” or “distress” and re-read these articles
without altering other aspects of the text. In some cases, the conclusions may still make sense
when reinterpreted (e.g., if AAQ/negative emotion correlates with exercise habits), but in many
cases (e.g., if AAQ/negative emotion correlates with another measure of negative emotion), they
will inevitably not be informative at all. We have no idea how many of these studies will be
affected. However, it might make sense to avoid any sweeping claims surrounding PF unless
speaking specifically about findings from studies that included a valid and reliable measure.
There are some promising avenues in this regard mentioned below. Specifically, two other recent
putative PF measures (see Kashdan et al., 2020; Landi et al., 2021) have shown promise as
legitimate measures of PF, as distinct from neuroticism, but these are the exception rather than
the norm. While there is clear evidence of progress in PF measurement validation from within
ACT, we must be careful not to tally studies that used invalid measures when quantifying the
existing evidence base for PF within ACT. Similarly, if individual components of PF (e.g.,
cognitive fusion) mediate treatment outcomes within ACT, this is not necessarily evidence that
PF as a whole mediates treatment outcomes unless all its components are included in the
mediation model. In this case, in the interest of (i) accuracy and (ii) not making things more
abstract, we might simply refer to those specific components as being the mediators for that
specific outcome rather than invoking PF and thereby all its other untested constituents.
Advances in Measuring Psychological Flexibility
Several other putative measures of PF have been developed without the use of a negative
emotion/neuroticism scale in their validation studies that would allow them to assess its construct
validity (Ciarrochi et al., 2022; Francis et al., 2016; Gloster et al., 2021; Thompson et al., 2019).
Where they have examined construct validity, they have not predicted clinical symptoms over
and above these other factors (Benoy et al., 2019) showing that they have poor incremental
criterion validity.
While there are several alternative putative measures of PF, most of these do not provide
any evidence that they measure PF as a distinct construct from trait negative emotion (see
Gloster et al., 2021; Thompson et al., 2019). One promising exception is the recently-validated
Multidimensional Psychological Flexibility Inventory (MPFI; Landi et al., 2021; Rolffs et al.,
2018). In Rolffs et al. (2018), an exploratory factor analysis suggested 12 Hexaflex factors
(loading onto “flexibility” and “inflexibility”, respectively) rather than six. Nonetheless,
subsequent structural equation models reported by Landi et al. shows, with good model fit, the
AAQ-II loading onto a “distress” factor alongside measures of anxiety and depression, and the
MPFI’s Hexaflex factors loading onto a unique factor that the authors call “psychological
flexibility” (these factors were correlated at -.57). As such we might recognize the MPFI as a
promising measure of PF and the most comprehensive evidence for the Hexaflex model
available, cautioning that a relative minority of ACT studies are based on this measure and so
sweeping conclusions are to be avoided. However, Kashdan et al. (2020) criticize this measure
for not relating the items to meaningful life goals.
Another exception is the recently developed Personalized Psychological Flexibility Index
(PPFI; Kashdan et al., 2020). In the validation study for this measure, the authors reported that
PF can be distinguished from negative emotion/neuroticism, both structurally and in terms of
incremental predictive validity. Specifically, respondents to the PPFI are asked about their
emotional experiences and behaviors in relation to a valued goal that participants specify at the
beginning of the questionnaire. This addresses the perceived limitation of the MPFI, but without
measuring the Hexaflex sub-factors. Conceivably, however, scores on such a measure might vary
(and therefore be more or less reliable) in accordance with how salient the specified goal is for a
particular respondent. It remains to be determined, therefore, whether this addition will be a
strength or limitation of the PPFI. Interestingly, this issue bears on another important concern;
namely the issue of value clarification in ACT, which we address in the next section.
Summary
In summary, ACT therapists and researchers say that PF is the core process of change in
psychotherapy. Thus, ACT researchers would ideally be able to demonstrate that “changes in PF
mediate the relationship between pre-therapy valued action/negative emotion and post-therapy
valued action/negative emotion”. However, most studies to date instead may have merely shown
that “changes in negative emotion mediate the relationship between pre-therapy valued
action/negative emotion and post-therapy valued action/negative emotion”, which does not speak
to the mechanisms of action in ACT. Indeed, if a reduction in negative emotion is the main
mediating mechanism of change in ACT, this is arguably more consistent with CBT, which aims
to change cognitive and emotional states themselves, rather than what ACT aims to do, which is
to change how we relate to negative thoughts and emotions and behave in their presence. The
PPFI and MPFI are well-validated measures overall that may represent constructive ways
forward here, but with each having unique advantages over the other. Regarding the putative
Hexaflex structure of PF, we might zoom out for a moment and ask why different numbers of PF
sub-factors are found by different authors? Disentangling this might be an important area of
future research, especially for a party with no vested interests in confirming any given factor
structure.
Jumping the Gun: No Valued Action Without Value Clarity
Disengaging from negative thoughts and emotions, such that they do not dictate our
behavior, is synonymous with the “Acceptance” aspect of ACT. However, this is in service of
establishing VCB or “valued action”; the “Commitment” aspect of ACT. For example, someone
may have negative thoughts such as “trying is pointless, someone always ruins everything good I
do”. An ACT practitioner could intervene using a mindfulness intervention to reduce the
automaticity of their client’s behavior (e.g., staying in bed all day) in accordance with this
thought. At this point, the client is psychologically enabled to act out their values (e.g., “I have
these thoughts, and they may or may not be true, but I will dedicate my time towards being an
attentive partner [valued action], come what may”). However, the client is equally free to act out
values they think or wish they held (self-deception), or are compelled to say they hold (social
coercion), but ultimately do not. This is why effective value clarification is so important for
clients: they need to understand what their own values are, and what their ideal (and indeed,
moral) identity is, as distinct from others’.
Value Clarity and Valued Action are Conflated

Our values are not infinitely malleable. For example, we know from a vast differential
psychology literature that our personalities (e.g., valuing safety, valuing social connection,
valuing ideas and alternative perspectives, valuing hard work and order, valuing cooperation;
Anglim et al., 2017) are, to at least some extent, reflective of biological interpersonal differences
(Smith & Hatemi, 2020; Vukasovic & Bratko, 2015), which may suggest at least some
limitations on their malleability. On the other hand, our values can be subject to local coercive
influence. For example, sex differences in values (Schwartz & Rubel-Lifschitz, 2009), interests
(Jiang et al., 2018), and personalities (Schmitt et al., 2008, 2017) are largest in countries where
men and women are freer from social coercion. This demonstrates the potential role of culture on
self-reported personal values. Perceived VCB may not have the desired salutary effects on
mental health if people are coerced into espousing values that go against their temperaments
and/or they ultimately just do not hold. It may be preferable for therapists to create conditions
under which individuals are freer to articulate individual differences in what they value (as in the
freer societies mentioned above), helping clients to negotiate with others how they express their
unique selves across contexts. This allows us to appreciate both individual differences and the
role of biological and cultural context. If people act in accordance with someone else’s values,
this likely means that they ultimately have not engaged in valued action. In contrast, an
individual may be quite clear on what their values are but perceive themselves not to be acting
them out. In this scenario, we might expect individuals to be distressed, as every ideal we specify
is also a criterion for failure (see Wood et al., 2009). Alternatively, someone might neither be
clear on their values nor be acting in accordance with them, in which case we might expect them
to be low in positive emotion and disengaged. Therefore, it is quite important to distinguish the
concept of valued action from value clarity.

At present, valued action and value clarity appear to be somewhat conflated within the
ACT literature. For example, the Engaged Living Scale (Trindade et al., 2016; Trompetter et al.,
2013) includes items like; “I make choices based on my values” (valued action) within the same
subscale as items such as: “I have values that give my life more meaning” (value clarity).
Similarly, the Behavioral Activation for Depression Scale (Kanter et al., 2007; Manos et al.,
2011) and the Valuing Questionnaire (Smout et al., 2013) mostly measure valued action but not
value clarity. Other measures like the Valued Living Questionnaire (VLQ; Wilson et al., 2010)
simply provide various life domains (e.g., Work, Parenting) and ask people to rate the extent to
which they value these domains. This does not fit well with values as conceptualized within
ACT, wherein values are qualities of our actions (patient, brave etc.), rather than areas that we
value (parenting, work etc.), as outlined above; we do not behave parent-ly, for example. More
importantly for purposes of the present point though, these ratings on the VLQ could be provided
without necessarily having thought these through properly. Indeed, the very act of providing
these ratings may alter what we value, making the VLQ potentially more akin to a value
clarification exercise than a measurement tool. While we do not claim that these tools are
without their own merits, this nonetheless points to a potential lack of consistency in the purpose
and methods of these various scales, with none of them clearly measuring value clarity as a
distinct construct.
The Utility of Values Exercises
Establishing VCB appears to be an important part of the process of change in ACT. For
example, one study by Sonntag et al. (2017) found that increasing VCB using ACT preceded a
reduction in psychological suffering. Similarly, Grégoire et al. (2021) showed that greater
variability in valued action was associated with increases in distress and lower wellbeing. These
findings cohere with ACT’s core thesis, that correcting dysfunctional schemas (per CBT) is not
necessary to live a meaningful and engaged life, and furthermore, that alleviating suffering is at
least partially a by-product of valued action, rather than the other way around.
Value clarification exercises (VCEs) are intended to help us to discover and articulate
which personal qualities we would most like to exhibit in our day-to-day actions. However, here
we might introduce some conjecture to highlight potential scenarios in which a robust research
program on the safety and efficacy of VCEs would be informative. More specifically, in the
absence of evidence based VCEs, it is possible that ACT therapists might inadvertently have a
larger than necessary proportion of clients pursue what is merely perceived VCB that will
ultimately lead to more long-term psychological suffering. Moreover, VCEs have the potential to
be harmful for those who hypothetically might stand to benefit from ACT the most. For example,
positive self-statements (which might include statements of behavior/value alignment) can
induce negative affect in those with low self-esteem (Wood et al., 2009). Analogously, it is also
plausible that specifying a well-thought-through ideal (e.g., a value, following a VCE) might
induce negative affect in those who perceive themselves to be far from that ideal; as previously
mentioned, every ideal is also a criterion for failure. It is incumbent upon ACT researchers,
therefore, to not only conduct necessary component studies on PF and RFT, but to also develop a
science aimed at identifying evidence-based methods of value clarification that are both safe and
efficacious for vulnerable people.
At present, there is some literature to support the benefits of including a values
component in psychological interventions, compared to not including such a component. In the
clinical domain, for example, including a values component helps to increase ‘approach’
behaviors in the presence of aversive stimuli (Hebert et al., 2021), and may help to increase pain
tolerance in cold-pressor tasks (Branstetter-Rost et al., 2009). In addition, within education,
elaborating on goals and how they relate to one’s life (i.e., increasing value salience) appears to
make people more motivated to achieve them. This has a disproportionately positive effect on
gender and ethnic minorities within education (Chase et al., 2013; Morisano et al., 2010;
Schippers et al., 2015, 2020). When students reflect on and clarify their values it also helps to
later increase their resilience to social ostracism; an important part of maintaining mental
hygiene (Hochard et al., 2021). Across these domains, we might reasonably speculate that our
values give us reason to persist with tasks when we experience difficulties, and this indeed
appears to be the case across a range of different contexts.
Evidence-Based Value Clarification vs Naïve Realism
These kinds of research studies do little to inform therapists of the best methods of
helping clients to clarify their values. For example, value card sort tasks are popular methods of
helping people to prioritize some value dimensions over others in the clinic, and these are
marketed to practitioners (see Harris, 2021; Morris, 2021; Value Sort, 2021). At the same time,
value card sort tasks are also used as measurement tools within the ACT literature (see Barrett et
al., 2020), highlighting another difference between what practitioners do and the available
research. Other popular VCEs like The Sweet Spot (Wilson & Sandoz, 2010) involve consciously
remembering a time in one’s life in which everything fit into place, reflecting on the values this
speaks to. Others are future-oriented, involving imagining what you would like someone to say
about you in a birthday speech (Viskovich et al., 2021), or on your tombstone (Hayes, 2004).
The effectiveness of these VCEs remains largely untested (with some exceptions; e.g., Sandoz &
Hebert, 2015), meaning that therapists are proceeding to implement these techniques in the
absence of a robust body of supporting evidence. In future research, it may be beneficial to test
whether there are near transfer effects of VCEs such that they improve value clarity, and
subsequently, far transfer towards valued action and wellbeing.
No doubt, these VCEs may be subjectively acceptable to clients and therapists and
subjectively efficacious, but these are not sufficient bases for evidence-based practice. Given the
current absence of scientific evidence for (or against) their efficacy, their current use in practice
might also reflect naïve realism, leading clinicians to conclude erroneously that client change is
due to an intervention itself rather than to a host of competing explanations (see Lilienfeld et al.,
2013). Indeed, several researchers (Garb, 2005; Grove & Meehl, 1996; Kahneman, 2011) have
also argued that clinical intuition and individual client responses are poor ways to judge an
intervention’s efficacy. Furthermore, negative iatrogenic effects may occur (Bootzin & Bailey,
2005). Moreover, Lilienfeld and his colleagues (2013) argued that client acceptability and
practitioner expertise are but two of three legs on the stool of evidence-based practice in clinical
psychology (the other being what the research shows to be efficacious once individual
preferences/biases of therapists and clients are controlled for).
Measuring Valued Action: Talk is Cheap
Measurement of valued action might also be improved upon by a greater focus on real-
world measures of behavior rather than self-estimations alone (e.g., caring about the environment
can be inferred by functional analyses of past pro-environmental actions). Most measures of
valued action (e.g., those listed above) involve self-reports of introspected values, which are poor
predictors of real-world behavior (see Baumeister et al., 2007). This general reliance on self-
reports within ACT in by no means unique to ACT but is nonetheless in opposition to the kind of
direct observation of behavior that is a hallmark of radical behaviorism, the philosophical
tradition from which ACT emerged. This is not to detract from, but to reinforce, ACT studies
that do have behavioral/real world outcome measures of course. For example, Bach and Hayes
(2002) include rehospitalization rates as their outcome measure, and Jennifer Gregg et al. (2007)
looked at A1C blood levels. Such studies present an opportunity for unbiased parties to replicate
these studies, perhaps with better statistical power, to help us have confidence in these
findings/effects. Thereafter, boundary conditions of these effects might be explored. The issue of
non-behavioral measurement is not necessarily fully remedied by using ecological momentary
assessments, as these are also self-reports for the most part. Indeed, the most recent short
measure of psychological flexibility which has been developed for this purpose has also not been
clearly distinguished from distress/negative emotionality (Gloster et al., 2021). It would therefore
be both conceptually and practically invaluable to develop measures of valued action that are
more transparent indicators of what they aim to index.
Functional Contextualism: The Means Justify the Ends
Underlying the broader approach to ACT and its putative processes is its philosophy,
making this the most fundamental issue to address when assessing any aspect of ACT. Here we
contend that FC might affect the therapeutic process, and also the process of research
dissemination within ACT. In accordance with the underlying philosophy of functional
contextualism (FC), CBS adopts a pragmatic truth criterion: that something is true or not insofar
as it is useful in moving the individual closer to goals or values ends (Hayes, 1993). In FC, there
is no place for ontological reality and Truth (D. Barnes-Holmes, 2000). Consequently, there is
also no room for absolutes, including moral absolutes. Instead, our own values are ushered in as
the yardstick against which all actions are judged, elevating their importance above all else.
There has been relatively little written to date on how FC applies to the practicing clinician and
their therapeutic processes (i.e., client-therapist interactions), nor how it applies to meta-science
issues (e.g., which findings on the process/efficacy of ACT we disseminate or ignore). In this
section, we argue that the moral relativist ethic imposed by FC is perhaps the most fundamental
issue with which ACT must contend.
Ruiz and Roche (2007) raised the ethical concern that the FC approach to scientific truth
allows just about any applied practice to be defined as “truthful” (i.e., useful) if it is deemed
personally to be useful for the therapist in a given context. This is a problematic underlying ethic.
It is true that, in ACT, client values should be “freely chosen” (Wilson et al., 2010) in that they
should be free from coercion (i.e., they are not influenced by the therapist). On the other hand,
once values are freely chosen by the client, a CBS practitioner operating strictly within the FC
paradigm necessarily views their own values as the only possible guide to their own therapeutic
strategy, whether this complements those of the client in terms of outcomes or not (e.g., the
therapist may wish to explore certain issues in the hope of publishing an interesting case study to
achieve a valued professional end). It is likely that this is very rarely an issue because most core
values overlap considerably across individuals (see Kostina et al., 2015) and, indeed, unethical
practices can occur in any field. Nonetheless, any course of action is, in principle,
philosophically justifiable for an ACT therapist who fully subscribes to FC insofar as their own
behavior, as an act-in-context, is pragmatically workable always in relation to valued outcomes.
It would be impossible to accuse a disciplined and ejected member of ACBS, who operated in
way destructive to the community, of operating outside of the FC paradigm if they had operated
always in the service of their own valued ends in a workable way (e.g., if their values deemed it
necessary to destroy ACBS). Ironically, the individual would have betrayed the publicly stated
values of ACBS, but at the same time would simultaneously have functioned as an efficient and
impeccable functional contextualist. Threat of legal and professional sanctions surely form part
of the context in which the therapist (or researcher) will identify a course of action as workable.
However, requiring values to be stated publicly or codes of ethics to be signed up to only
partially mitigates against morally unacceptable behavior. After all, history is replete with
examples of individuals committing ethical atrocities for The Greater Good with public support.
The important point here, however, is that FC is unique as a world view in permitting the
individual practitioner to decide for themselves if a given course of action is moral, not only with
respect to community norms and values (the main ethical imperative for other professionals), but
also in relation to how a given course of action helps the individual reach personally valued ends.
While these valued ends are invited for public airing by all ACBS members, this is not a very
coherent risk management system when privately subverting one’s publicly stated values can
itself serve as a workable (therefore truthful) action within FC, so long as doing so realizes
valued ends. For instance, it would be consistent with FC for an ACBS member to subvert
community values, tell untruths, falsify data, or whatever it took to precipitate the wrongful
disciplining and ejection of certain members that they saw as threatening to the realization of
own valued ends, or those of ACBS. In any other professional ethical system we can think of,
such actions would be viewed as intrinsically immoral irrespective of any valued outcomes. In
contrast, in FC, such actions would have to be viewed as intrinsically moral and “true”, even
where they contravened publicly stated community ethics and values. Put simply, FC is a
relativistic moral framework and with that comes particular dangers not familiar to other
psychologists.
FC might negatively affect the ACT research and dissemination processes in practice in
ways that are difficult to quantify or indeed confirm. For example, an organization, such as
ACBS, could state their values publicly (e.g., to promote the interests of CBS [i.e., ACT and
RFT]) and in order to serve these values, members could subsequently ignore challenging
research or ostracize individuals who contributed a critical view. This behavior is antithetical to
the general scientific effort to mitigate against our individual biases with methodological rigor,
and it is ultimately against client interests if we truly believe in the scientist-practitioner model of
psychotherapy. Again, this may rarely if ever happen within ACBS. However, it is critical to
understand that these occurrences would be philosophically permissible under FC, wherein the
satisfaction of our personal values, after taking account of contextual affordances, is the only
viable and ultimate guide to the veracity of our truth claims (see Hayes, 1993; Ruiz & Roche,
2007).
The FC philosophy might also negatively affect the client’s behavior. For example, a
therapist could support the client in reaching their goals by any means necessary (rendering those
means truthful) so long as they are comfortable that these goals and means are in line with
personal values. Indeed, lying to the therapist about their personal values may also be part of that
“truthful” action on the part of the client, if doing so got them from A to B, so to speak. In effect,
there is no intrinsic value system in FC, even if there is one in ACBS. Such a system has been
explicitly avoided to prevent the threat of dogmatism (see Hayes, 1993). What is left, however, is
a system so malleable as to, at least in principle, be open to abuse for nefarious purposes.
One potential counterargument against this perspective is that FC-adherent ACT
therapists are bound by broader professional ethical standards that would not allow harm to a
client. However, FC is a “pre-analytic” philosophy, meaning that it applies to the individual’s
worldview before they even decide whether to adhere to those guidelines at all. For example, one
might ensure not to get caught breaking ethical guidelines without necessarily adhering to the
spirit of those guidelines across contexts. The ACBS has a values statement, “Throughout the
ACBS community, we work in a collegial, open, generous, self-critical, non-discriminatory, and
mutually supportive way” (https://contextualscience.org/acbs), but the pre-analytic nature of FC
undermines how seriously such a statement can be taken from without. It may simply be useful
to be seen to make such a statement in one context but adhering to this statement may no longer
be ‘useful’ in another.
This relativist pre-analytic philosophy might also extend towards what gets published and
what gets cited, thus affecting practitioner perceptions of extant evidence bases. For example,
bias in research interpretation and reporting is arguably evident in the recent failure to
acknowledge Pendrous et al.’s (2020) non-replication of Sierra et al.’s (2016) findings in a later
chapter in the Oxford Handbook of Acceptance and Commitment Therapy (Luciano et al., 2021),
and in a recent journal article (Ramírez et al., 2021) in which this research agenda was discussed.
Similarly, this non-replication was not cited in at least one more recent article (Falletta-Cowden
et al., 2022) by a different CBS research group that referenced Sierra et al. (2016). Our aim here
is not to discuss the specifics of this research program, as this is discussed elsewhere (e.g.,
Hulbert-Williams et al., 2020). We certainly cannot speak to the reasons behind these specific
instances of citation bias either; many of these authors may not have even been aware of the non-
replication’s existence for all we know. However, we must recognize that omitting such a study
would, in principle, be entirely permissible from a FC perspective (e.g., if it was ‘not useful’ to
disrupt the narrative, in the context of what researchers wanted to achieve). This is an important
example because it highlights how practitioners’ perceptions of the evidence base for ACT’s
practical processes and mechanisms of change could potentially be misguided because of the
ACT research community’s instrumentalist/moral relativist philosophy.

Ironing out this fundamental philosophical wrinkle may threaten the internal coherence of
functional contextualism, or CBS, or both, as a philosophy to underlie ethical, evidence-based
practice with vulnerable individuals. Nonetheless, it is one worth addressing in the interests of
integrating ACT with more widely used therapeutic approaches that adopt more absolutist ethical
principles (e.g., “first, do no harm” or “tell the full story, even if it is inconvenient”), and with a
mainstream view of science that has been fit for purpose in virtually every other scientific field.
Until ACT and other FC-oriented psychotherapies have a non-relativistic pre-analytic
philosophical bedrock, there is no reason to trust research on the processes (and indeed, efficacy)
of ACT, unless this comes from disinterested parties who are not moral relativists; a true FC
would only report on that which it is useful for them to report.
Summary and Recommendations
This article has highlighted some conceptual and empirical gaps in the ACT literature
that affect our understanding of the inter- and intra-personal processes of psychological change
in ACT, and the therapeutic process. However, these limitations are only highlighted here with a
view to proposing potential solutions and opportunities for future research. Given the length of
this article, it seems prudent to summarize these recommendations for the reader in what follows:
Recommendations Regarding Psychological Flexibility
First, it might be appropriate to avoid making blanket statements about psychological
flexibility based on AAQ-related research papers. Such papers do not need to be
disregarded/thrown out, and indeed, nor do the AAQ measures themselves, but these studies do
need to be reinterpreted, and general conclusions about PF re-evaluated and tempered
accordingly. Secondly, we need to commit to adopting robust measures of PF that are
meaningfully distinguished from measures of negative emotion before making truth claims about
PF. This will be important to help avoid Type 1 errors in research studies and muddying the ACT
and PBT literature with conceptual confusion.
Caution should also be exercised in claiming that PF (i.e., all six Hexaflex components
working together) is the core process of change in ACT when, in reality, it is more common to
see one or two of PF’s components as mediators in any given study. In the interim, there is
nothing wrong with simply saying that mindfulness, exposure, or valued action (etc.) are the
processes of change for particular applications of ACT if that is what was measured in individual
studies, or indeed that their effects are moderated by trait negative emotion levels. Not only
would this be more accurate, but conceptually speaking, it allows ACT therapists to then draw
upon well-established non-ACT research literatures on these constructs to inform their evidence-
based practice. While it is understandable that many ACT practitioners will be keen to
emphasize PF as a core process of change in ACT for reasons of conceptual coherence with the
ACT literature, such enthusiasm may be premature given the evidence base. While promoting
coherent theoretical positions serves community building purposes well, it can ultimately do a
disservice to the science and evidence-based practice, and thereby the vulnerable clients with
whom psychotherapists work.
Recommendations Regarding Relational Frame Theory
In a similar vein, ACT proponents should consider the appropriateness of implying (e.g.,
in writing and in workshops) that ACT therapy can be improved upon by including RFT
components (see Barnes-Holmes, 2015; Villatte, 2018). The extant literature base simply does
not support such a conclusion at the current time, even if some developments may appear
promising. Instead, it may be better to say that ACT was co-developed with RFT and aspires to
be consistent with this approach to language and cognition. Insofar as this is the case, RFT may
provide the opportunity to develop therapeutic interventions that are technically precise and
understood functionally from the ground up. However, this is certainly not the case at present,
and we believe that no single RFT-based treatment for any form of psychopathology has been
empirically well-validated at this point. The suggestion that such treatments might augment ACT
or that they are on the near horizon is highly speculative and potentially misleading to
stakeholders (including practitioners) who may not be equipped to critically evaluate such
claims.
Given that a large proportion of RFT empirical literature is made up of implicit bias
research (not directly relevant to clinical practice) and single-subject and low-N design studies
(from which it is difficult to extract general principles), it may be beneficial to focus on
strengthening the foundations of RFT. This might involve large-scale replication projects and
more clinical RFT research from unbiased parties. It is notable, and concerning, that in a recent
ACBS task force report on future directions within ACT/RFT (Hayes, Merwin, et al., 2021),
increasing methodological quality control via replication of key findings in ACT/RFT research
was not one of the 33 recommendations made. On the other hand, ACBS have recently
announced that their journal, JCBS, will soon begin to accept registered reports, which is a
positive step forward. Finally, it may be of benefit to conduct a systematic review of RFT
literature akin to O’Connor et al. (2017), with closer scrutiny of the quality and impartiality of
such studies (e.g., May et al., 2022), and less emphasis on the quantity of RFT studies, so that
both RFT proponents and critics can avoid making misleading statements one way or the other.
Recommendations Regarding Valued Action and Value Clarity
PF, and at a more basic level, RFT, are purported to be important mechanisms of
psychological change within ACT. However, most PF/RFT components are mere means to an
end; valued action is explicitly the behavioral outcome sought within ACT. Arguably, the ACT
model should then include some evidence-based way to ensure that individual clients can
understand what their values are in the first place. It is not unheard of for someone to act out one
set of values in their life and then to realize that they hold an entirely different set of values (e.g.,
a ‘mid-life crisis’; Oles, 1999). For this reason, clinicians who mean to practice values-focused
therapies like ACT should have expertise in helping clients to discover, articulate, and iteratively
refine their value systems over time. We cannot have evidence-based practice in the use of value
clarification exercises without a robust science of value clarification. To develop a science of
value clarification, it is important to have measures of value clarity that are not conflated with
valued action. This is an important area to develop within ACT because without a body of
research upon which to base practice, there cannot be experts on this topic. In turn, without
expertise, it is possible that ACT will be delivered sub-optimally, or worse, increase the
probability that therapists might inadvertently cause longer-term harm to clients.
Recommendations Regarding Functional Contextualism
We argue here that there is a clear moral gap in ACT’s core philosophy that would seem
to permit the expedient subversion of ethical practice. As such, what a FC does/does not say/do
must be functionally assessed rather than taken at face value. This is because FC is a pre-analytic
philosophy with no moral imperative onto which we cannot bolt a moral framework in a
Frankenstein-esque manner. This, at least in principle, increases the risk of ethical problems
around conflicts of interest, especially in studies with higher researcher degrees of freedom,
making independent replication by unbiased parties all the more important for FC-oriented
psychotherapies such as ACT. Additionally, should a therapist’s a-moral and instrumentalist
philosophy bleed into their clinical practice, this may have negative iatrogenic effects for the
client. Given that FC is the pre-analytic backbone of all aspects of CBS, this is to call for a rather
fundamental re-consideration of the philosophical foundations of CBS itself on moral grounds,
even where doing so questions the CBS paradigm itself. Not all practitioners of ACT are ACBS
members nor are they necessarily well-read in philosophy. Therefore, we hope that by providing
verbal discriminative stimuli (i.e., within this paper) to help researchers and therapists respond to
these conceptual/moral inconsistencies, improvements can be made to CBS as a framework for
ethical psychological science going forward. We recognize that key hypotheses in psychology
are seldom falsified (Haeffel, 2022) and thereby ideas are seldom changed. Amending a
philosophy post-hoc is likely to be even harder as it is even more deeply rooted than pet
hypotheses, but on the other hand, we must be wary of sunk costs (see Olivola, 2018).
Conclusion
There is a large array of evidence that ACT works approximately as well as CBT for a
range of symptoms (A-Tjak et al., 2015), albeit with a few impartial critics arguing otherwise
(Öst, 2017). However, the question as to how ACT works is still an open and empirical one, and
not a philosophical, theoretical, nor rhetorical one. We are perhaps further away from a
legitimate PBT in ACT than might first appear when considering the empirical research base
critically. In answering the question of what the active inter- and intra-personal processes of
change in ACT might be, it is important to separate what can be verified empirically from the
theoretical position of ACT. Many consumers of clinical psychological science are not likely to
be qualified (i.e., have extensive research methods training) to critically evaluate this difference
and can easily be misled, unintentionally leading to misplaced enthusiasm for and confidence in
the science. This might ultimately negatively impact vulnerable clients as narrative and naïve
realism takes over. This danger of misplaced confidence in the science is illustrated in a recent
article by Hayes et al. (2022, p. 24) who say:
“Because we wished to examine the usefulness of the [new conceptual model for PBT] in
summarizing the existing mediational literature on processes of change, our present summary is
deliberately universalist and qualitative.
One of the headline findings from this paper is that psychological flexibility is the largest
replicated mediator of psychotherapeutic outcomes across all RCTs in the psychotherapeutic
literature from 1985-2018. This headline is misleading, in our opinion, given that most pre-2018
PF measures did not measure PF (though perhaps one or two of its processes at a time), and
given that CBT-related processes (e.g., dysfunctional thoughts and rumination/worry) are
separated out when quantifying the relative importance of replicated therapeutic mediators. They
continue:
We will leave for another day such issues as the quality of research that led to these findings, the
interventions that produce them, the diagnostic categories that were addressed, the outcomes
that were targeted, the effect sizes of processes of change, and other similar issues. All such
matters draw us closer to the world of “protocols for syndromes” and away from how to identify
and organize commonly useful processes of change.”
The present article argues that these specifics deliberately omitted by Hayes et al. (2022)
are all-important to our interpretations (see, for example, Johannsen et al., 2022), in addition to
several other issues mentioned herein (especially conflicts of interest, and ethical issues in
relation to the therapeutic process itself facilitated by FC). We hope that this article reveals
several areas that are ripe for scientific and philosophical inquiry on the inter- and intra-personal
processes involved in psychotherapy. Further research in these areas is not merely required for
the purpose of knowledge system building, nor intellectual satisfaction, but to satisfy real and
present ethical and moral obligations to our clients and the wider scientific community, as well
as to honor ACT’s stated commitment to bottom-up, functional-analytic, empirical, process-
based accounts of human behavior.

References
A-Tjak, J. G. L., Davis, M. L., Morina, N., Powers, M. B., Smits, J. A. J., & Emmelkamp, P. M.
G. (2015). A Meta-Analysis of the Efficacy of Acceptance and Commitment Therapy for
Clinically Relevant Mental and Physical Health Problems. Psychotherapy and
Psychosomatics, 84(1), 30–36. https://doi.org/10.1159/000365764
Anglim, J., Knowles, E. R. V., Dunlop, P. D., & Marty, A. (2017). HEXACO personality and
Schwartz’s personal values: A facet-level analysis. Journal of Research in Personality, 68,
23–31. https://doi.org/10.1016/j.jrp.2017.04.002
Bach, P., & Hayes, S. C. (2002). The use of acceptance and commitment therapy to prevent the
rehospitalization of psychotic patients: A randomized controlled trial. Journal of Consulting
and Clinical Psychology, 70(5), 1129–1139. https://doi.org/10.1037/0022-006X.70.5.1129
Barnes-Holmes, D. (2000). Behavioral pragmatism: No place for reality and truth. The Behavior
Analyst, 23(2), 191–202. https://doi.org/10.1007/BF03392010
Barnes-Holmes, Y. (2019). Enhancing your ACT practice with Relational Frame Theory (RFT) –
a Masterclass with Yvonne Barnes-Holmes. Contextual Consulting Website.
https://contextualconsulting.co.uk/previous-workshops
Barnes-Holmes, Y., Boorman, J., Oliver, J. E., Thompson, M., McEnteggart, C., & Coulter, C.
(2018). Using conceptual developments in RFT to direct case formulation and clinical
intervention: Two case summaries. Journal of Contextual Behavioral Science, 7, 89–96.
https://doi.org/10.1016/j.jcbs.2017.11.005
Barrett, K., O’Connor, M., & McHugh, L. (2020). Investigating the psychometric properties of
the Values Wheel with a clinical cohort: A preliminary validation study. Journal of
Contextual Behavioral Science, 15, 210–218. https://doi.org/10.1016/j.jcbs.2019.12.009

Baumeister, R. F., Vohs, K. D., & Funder, D. C. (2007). Psychology as the science of self-
reports and finger movements: Whatever happened to actual behavior? Perspectives on
Psychological Science, 2(4), 396–403. https://doi.org/10.1111/j.1745-6916.2007.00051.x
Beck, A. T. (1993). Cognitive therapy: Past, present, and future. Journal of Consulting and
Clinical Psychology, 61(2), 194–198. https://doi.org/10.1037/0022-006X.61.2.194
Benoy, C., Knitter, B., Knellwolf, L., Doering, S., Klotsche, J., & Gloster, A. T. (2019).
Assessing psychological flexibility: Validation of the open and engaged state questionnaire.
Journal of Contextual Behavioral Science, 12, 253–260.
Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., Waltz, T.,
& Zettle, R. D. (2011). Preliminary Psychometric Properties of the Acceptance and Action
Questionnaire-II: A Revised Measure of Psychological Inflexibility and Experiential
Avoidance. Behavior Therapy, 42(4), 676–688. https://doi.org/10.1016/j.beth.2011.03.007
Bootzin, R. R., & Bailey, E. T. (2005). Understanding placebo, nocebo, and iatrogenic treatment
effects. Journal of Clinical Psychology, 61(7), 871–880.
https://doi.org/10.1002/JCLP.20131
Branstetter-Rost, A., Cushing, C., & Douleh, T. (2009). Personal Values and Pain Tolerance:
Does a Values Intervention Add to Acceptance? The Journal of Pain, 10(8), 887–892.
https://doi.org/10.1016/J.JPAIN.2009.01.001
Chase, J. A., Houmanfar, R., Hayes, S. C., Ward, T. A., Vilardaga, J. P., & Follette, V. (2013).
Values are not just goals: Online ACT-based values training adds to goal setting in
improving undergraduate college student performance. Journal of Contextual Behavioral
Science, 2(3–4), 79–84. https://doi.org/10.1016/J.JCBS.2013.08.002

Ciarrochi, J., Sahdra, B., Hofmann, S. G., & Hayes, S. C. (2022). Developing an item pool to
assess processes of change in psychological interventions: The Process-Based Assessment
Tool (PBAT). Journal of Contextual Behavioral Science, 23, 200–213.
https://doi.org/10.1016/J.JCBS.2022.02.001
Ciarrochi, J. V., Bilich, L., & Godsell, C. (2010). Psychological flexibility as a mechanism of
change in Acceptance and Commitment Therapy. In R. A. Baer (Ed.), Assessing
mindfulness and acceptance processes in clients: Illuminating the theory and practice of
change (pp. 51–75). Context Press.
Corral, D., Kurtz, K. J., & Jones, M. (2018). Learning relational concepts from within- versus
between-category comparisons. Journal of Experimental Psychology: General, 147(11),
1571. https://doi.org/10.1037/XGE0000517
Criollo, A. B., Diaz-Muelle, S., Ruiz, F. J., & Garcia-Martin, M. B. (2018). Common physical
properties improve metaphor effect even in the context of multiple examples. The
Psychological Record, 68(4), 513–523.
Doorley, J. D., Goodman, F. R., Kelso, K. C., & Kashdan, T. B. (2020). Psychological
flexibility: What we know, what we do not know, and what we think we know. Social and
Personality Psychology Compass, 14(12), 1–11. https://doi.org/10.1111/spc3.12566
Dymond, S., & Barnes, D. (1995). A transformation of self-discrimination response functions in
accordance with the arbitrarily applicable relations of sameness and opposition.
Psychological Record, 46(2), 271–300. https://doi.org/10.1901/jeab.1995.64-163
Dymond, S., & May, R. (2018). Quantifying the Empirical Growth of Relational Frame Theory
Research: a Cautionary Note. Psychological Record, 68(2), 255–260.
https://doi.org/10.1007/S40732-018-0278-Z/FIGURES/2
Falletta-Cowden, N., Smith, P., Hayes, S. C., Georgescu, S., & Kolahdouzan, S. A. (2022). What
the Body Reveals about Lay Knowledge of Psychological Flexibility. Journal of Clinical
Medicine, 11(10), 2848. https://doi.org/10.3390/jcm11102848
Francis, A. W., Dawson, D. L., & Golijani-Moghaddam, N. (2016). The development and
validation of the Comprehensive assessment of Acceptance and Commitment Therapy
processes (CompACT). Journal of Contextual Behavioral Science, 5(3), 134–145.
Garb, H. N. (2005). Clinical judgment and decision making. Annual Review of Clinical
Psychology, 1, 67–89. https://doi.org/10.1146/annurev.clinpsy.1.102803.143810
Gloster, A. T., Block, V. J., Klotsche, J., Villanueva, J., Rinner, M. T. B., Benoy, C., Walter, M.,
Karekla, M., & Bader, K. (2021). Psy-Flex: A contextually sensitive measure of
psychological flexibility. Journal of Contextual Behavioral Science, 22, 13–23.
Gloster, A. T., Klotsche, J., Chaker, S., Hummel, K. V., & Hoyer, J. (2011). Assessing
psychological flexibility: What does it add Above and beyond existing constructs?
Psychological Assessment, 23(4), 970–982. https://doi.org/10.1037/a0024135
Gregg, A. P. (2007). When vying reveals lying: the timed antagonistic response alethiometer.
Applied Cognitive Psychology, 21(5), 621–647. https://doi.org/10.1002/ACP.1298
Gregg, J. A., Callaghan, G. M., Hayes, S. C., & Glenn-Lawson, J. L. (2007). Improving Diabetes
Self-Management Through Acceptance, Mindfulness, and Values: A Randomized
Controlled Trial. Journal of Consulting and Clinical Psychology, 75(2), 336–343.
https://doi.org/10.1037/0022-006X.75.2.336
Grégoire, S., Doucerain, M., Morin, L., & Finkelstein-Fox, L. (2021). The relationship between
value-based actions, psychological distress and well-being: A multilevel diary study.
Grove, W. M., & Meehl, P. E. (1996). Comparative efficiency of informal (subjective,
impressionistic) and formal (mechanical, algorithmic) prediction procedures: The clinical-
statistical controversy. Public Policy, and Law, 2, 293–323.
Haeffel, G. J. (2022). Psychology needs to get tired of winning. Royal Society Open Science,
9(6). https://doi.org/10.1098/RSOS.220099
Harris, R. (2021). Values cards help achieve goals and overcome barriers. ACT Mindfully.
https://www.actmindfully.com.au/product-category/values-cards/
Hayes, S. C. (2004). Acceptance and commitment therapy, relational frame theory, and the third
wave of behavioral and cognitive therapies. Behavior Therapy, 35(4), 639–665.
https://doi.org/10.1016/S0005-7894(04)80013-3
Hayes, S. C., Barnes-Holmes, D., & Roche, B. (2001). Relational Frame Theory: A post-
Skinnerian account of human language and cognition. Plenum Press.
Hayes, S. C., Barnes-Holmes, D., & Wilson, K. G. (2012). Contextual behavioral science:
Creating a science more adequate to the challenge of the human condition. Journal of
Contextual Behavioral Science, 1(1–2), 1–16. https://doi.org/10.1016/j.jcbs.2012.09.004
Hayes, S. C., Ciarrochi, J., Hofmann, S. G., Chin, F., & Sahdra, B. (2022). Evolving an
idionomic approach to processes of change: Towards a unified personalized science of
human improvement. Behavior Research and Therapy.
Hayes, S. C., Hofmann, S. G., Stanton, C. E., Carpenter, J. K., Sanford, B. T., Curtiss, J. E., &
Ciarrochi, J. (2019). The role of the individual in the coming era of process-based therapy.
Behaviour Research and Therapy, 117, 40–53. https://doi.org/10.1016/j.brat.2018.10.005
Hayes, S. C., Law, S., Assemi, K., Falletta-Cowden, N., Shamblin, M., Burleigh, K., Olla, R.,
Forman, M., & Smith, P. (2021). Relating is an operant: A fly over of 35 years of RFT
research. Perspectivas Em Análise Do Comportamento, 1–28.
https://doi.org/10.18761/pac.2021.v12.rft.02
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and
commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy,
44(1), 1–25. https://doi.org/10.1016/j.brat.2005.06.006
Hayes, S. C., Merwin, R. M., McHugh, L., Sandoz, E., A-Tjak, J., Ruiz, F. J., Barnes-Holmes,
D., Bricker, J. B., Ciarrochi, J., Dixon, M. R., Fung, K., Gloster, A. T., Gobin, R. L., Gould,
E. R., Hofmann, S. G., Kasujja, R., Karekla, M., Luciano, C., & McCracken, L. M. (2021).
Report of the ACBS task force on the strategies and tactics of Contextual Behavioral
Science research. Journal of Contextual Behavioral Science, 20, 172–183.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy:
Understanding and treating human suffering. Guildford Press.
Hayes, S. C., Strosahl, K., Wilson, K. G., Bissett, R. T., Pistorello, J., Toarmino, D., Polusny, M.
A., Dykstra, T. A., Batten, S. V., Bergan, J., Stewart, S. H., Zvolensky, M. J., Eifert, G. H.,
Bond, F. W., Forsyth, J. P., Karekla, M., & Mccurry, S. M. (2004). Measuring experiential
avoidance: A preliminary test of a working model. The Psychological Record, 54(4), 553–
578. https://doi.org/10.1007/BF03395492
Hebert, E. R., Flynn, M. K., Wilson, K. G., & Kellum, K. K. (2021). Values intervention as an
establishing operation for approach in the presence of aversive stimuli. Journal of

Contextual Behavioral Science, 20, 144–154. https://doi.org/10.1016/j.jcbs.2021.04.001
Hochard, K. D., Hulbert-Williams, L., Ashcroft, S., & McLoughlin, S. (2021). Acceptance and
values clarification versus cognitive restructuring and relaxation: A randomized controlled
trial of ultra-brief non-expert-delivered coaching interventions for social resilience. Journal
of Contextual Behavioral Science. https://doi.org/10.1016/j.jcbs.2021.05.001
Hofmann, S. G., & Hayes, S. C. (2019a). The future of intervention science: Process-based
therapy. Clinical Psychological Science, 7(1), 37–50.
https://doi.org/10.1177/2167702618772296
Hofmann, S. G., & Hayes, S. C. (2019b). Therapeutic change processes link and clarify targets
and outcomes. World Psychiatry, 18(3), 287–288. https://doi.org/10.1002/wps.20664
Hofmann, S. G., & Hayes, S. C. (2020). Beyond the DSM: Toward a process-based alternative
for diagnosis and mental health treatment. Context Press.
Hulbert-Williams, L., Pendrous, R., Hochard, K. D., & Hulbert-Williams, N. J. (2020). In search
of scope: A response to Ruiz et al. (2020). In Journal of Contextual Behavioral Science
(Vol. 18, pp. 306–311). Elsevier Inc. https://doi.org/10.1016/j.jcbs.2020.10.008
Jiang, S., Schenke, K., Eccles, J. S., Xu, D., & Warschauer, M. (2018). Cross-national
comparison of gender differences in the enrollment in and completion of science,
technology, engineering, and mathematics Massive Open Online Courses. PLoS ONE,
13(9), e0202463. https://doi.org/10.1371/journal.pone.0202463
Johannsen, M., Nissen, E. R., Lundorff, M., & O’Toole, M. S. (2022). Mediators of acceptance
and mindfulness-based therapies for anxiety and depression: A systematic review and meta-
analysis. Clinical Psychology Review, 94, 102156.
https://doi.org/10.1016/J.CPR.2022.102156
Jost, J. T. (2019). The IAT is dead, long live the IAT: Context-sensitive measures of implicit
attitudes are indispensable to social and political psychology. Current Directions in
Psychological Science, 28(1), 10–19. https://doi.org/10.1177/0963721418797309
Kahneman, D. (2011). Thinking fast and slow. Farrar, Strauss, & Giroux Inc.
Kanter, J. W., Mulick, P. S., Busch, A. M., Berlin, K. S., & Martell, C. R. (2007). The
Behavioral Activation for Depression Scale (BADS): Psychometric properties and factor
structure. Journal of Psychopathology and Behavioral Assessment, 29(3), 191–202.
https://doi.org/10.1007/s10862-006-9038-5
Kashdan, T. B., Disabato, D. J., Goodman, F. R., Doorley, J. D., & Mcknight, P. E. (2020).
Understanding psychological flexibility: A multimethod exploration of pursuing valued
goals despite the presence of distress. Psychological Assessment, 32(9), 829–850.
https://doi.org/10.1037/pas0000834
Kazdin, A. E. (2007). Mediators and mechanisms of change in psychotherapy research. Annual
Review of Clinical Psychology, 3, 1–7.
https://doi.org/10.1146/annurev.clinpsy.3.022806.091432
Kostina, E., Kretova, L., Teleshova, R., Tsepkova, A., & Vezirov, T. (2015). Universal Human
Values: Cross-Cultural Comparative Analysis. Procedia - Social and Behavioral Sciences,
214, 1019–1028. https://doi.org/10.1016/j.sbspro.2015.11.696
Landi, G., Pakenham, K. I., Crocetti, E., Grandi, S., & Tossani, E. (2021). The Multidimensional
Psychological Flexibility Inventory (MPFI): Discriminant Validity of psychological
flexibility with distress. Journal of Contextual Behavioral Science.
Levin, M. E., Hildebrandt, M. J., Lillis, J., & Hayes, S. C. (2012). The Impact of Treatment
Components Suggested by the Psychological Flexibility Model: A Meta-Analysis of
Laboratory-Based Component Studies. Behavior Therapy, 43(4), 741–756.
https://doi.org/10.1016/J.BETH.2012.05.003
Lilienfeld, S. O., Ritschel, L. A., Lynn, S. J., Cautin, R. L., & Latzman, R. D. (2013). Why many
clinical psychologists are resistant to evidence-based practice: Root causes and constructive
remedies. Clinical Psychology Review, 33(7), 883–900.
https://doi.org/10.1016/J.CPR.2012.09.008
Lilienfeld, S. O., & Strother, A. N. (2020). Psychological measurement and the replication crisis:
Four sacred cows. Canadian Psychology, 61(4), 281–288.
https://doi.org/10.1037/cap0000236
Luciano, C., Törneke, N., & Ruiz, F. J. (2021). Clinical behavior analysis and RFT:
Conceptualizing psychopathology and its treatment. In M. P. Twohig, M. E. Levin, & J. M.
Petersen (Eds.), Oxford Handbook of Acceptance and Commitment Therapy (pp. 1–28).
OSF Preprints. https://doi.org/10.31219/OSF.IO/S4VWU
Maj, M. (2008). Non-financial conflicts of interests in psychiatric research and practice. In
British Journal of Psychiatry (Vol. 193, Issue 2, pp. 91–92). Cambridge University Press.
https://doi.org/10.1192/bjp.bp.108.049361
Manos, R. C., Kanter, J. W., & Luo, W. (2011). The Behavioral Activation for Depression Scale-
Short Form: Development and Validation. Behavior Therapy, 42(4), 726–739.
https://doi.org/10.1016/j.beth.2011.04.004
May, R. J., Stewart, I., Baez, L., Freegard, G., & Dymond, S. (2017). Arbitrarily applicable
spatial relational responding. Journal of the Experimental Analysis of Behavior, 107(2),
234–257. https://doi.org/10.1002/jeab.250
May, R. J., Tyndall, I., McTiernan, A., Roderique-Davies, G., & McLoughlin, S. (2022). The
impact of the SMART program on cognitive and academic skills: A systematic review and
meta-analysis. British Journal of Educational Technology, 00, 1–18.
https://doi.org/10.1111/BJET.13192
McHugh, L., Barnes-Holmes, Y., & Barnes-Holmes, D. (2004). Perspective-taking as relational
responding: A developmental profile. Psychological Record, 54(1), 115–144.
https://doi.org/10.1007/BF03395465
McLoughlin, S., & Stewart, I. (2017). Empirical advances in studying relational networks.
Journal of Contextual Behavioral Science, 6(3), 329–342.
McLoughlin, S., Tyndall, I., & Pereira, A. (2018). Piloting a brief relational operant training
program: analyses of response latencies and intelligence test performance. European
Journal of Behavior Analysis, 19(2), 228–246.
https://doi.org/10.1080/15021149.2018.1507087
McLoughlin, S., Tyndall, I., & Pereira, A. (2020). Convergence of multiple fields on a relational
reasoning approach to cognition. Intelligence, 83, 101491.
https://doi.org/10.1016/j.intell.2020.101491
Miguel, C. F., Frampton, S. E., Lantaya, C. A., Lafrance, D. L., Quah, K., Meyer, C. S., Elias, N.
C., & Fernand, J. K. (2015). The effects of tact training on the development of analogical
reasoning. Journal of the Experimental Analysis of Behavior, 104(2), 96–118.
https://doi.org/10.1002/JEAB.167
Morisano, D., Hirsh, J. B., Peterson, J. B., Pihl, R. O., & Shore, B. M. (2010). Setting,
elaborating, and reflecting on personal goals improves academic performance. Journal of

Applied Psychology, 95(2), 255–264. https://doi.org/10.1037/a0018478
Morris, J. J. (2021). The Values Deck | A card sorting game to explore your personal values.
Amazon: Discover Your Values. https://www.amazon.com/Discover-Your-Values-The-
Deck/dp/0578493616
Munder, T., Brütsch, O., Leonhart, R., Gerger, H., & Barth, J. (2013). Researcher allegiance in
psychotherapy outcome research: An overview of reviews. Clinical Psychology Review,
33(4), 501–511. https://doi.org/10.1016/j.cpr.2013.02.002
O’Connor, M., Farrell, L., Munnelly, A., & McHugh, L. (2017). Citation analysis of relational
frame theory: 2009–2016. Journal of Contextual Behavioral Science, 6(2), 152–158.
Oles, P. K. (1999). Towards a psychological model of midlife crisis. Psychological Reports,
84(3_suppl), 1059–1069. https://doi.org/10.2466/pr0.1999.84.3c.1059
Olivola, C. Y. (2018). The Interpersonal Sunk-Cost Effect. Psychological Science, 29(7), 1072–
1083. https://doi.org/10.1177/0956797617752641
Ong, C. W., Lee, E. B., Levin, M. E., & Twohig, M. P. (2019). A review of AAQ variants and
other context-specific measures of psychological flexibility. Journal of Contextual
Behavioral Science, 12, 329–346. https://doi.org/10.1016/j.jcbs.2019.02.007
Ong, C. W., Levin, M. E., & Twohig, M. P. (2020). Beyond Acceptance and Commitment
Therapy: Process-Based Therapy. The Psychological Record 2020 70:4, 70(4), 637–648.
https://doi.org/10.1007/S40732-020-00397-Z
Öst, L. G. (2017). Rebuttal of Atkins et al. (2017) critique of the Öst (2014) meta-analysis of
ACT. Behaviour Research and Therapy, 97, 273–281.
https://doi.org/10.1016/j.brat.2017.08.008
Pendrous, R., Hulbert-Williams, L., Hochard, K. D., & Hulbert-Williams, N. J. (2020).
Appetitive augmental functions and common physical properties in a pain-tolerance
metaphor: An extended replication. Journal of Contextual Behavioral Science, 16(1), 17–
24. https://doi.org/10.1016/j.jcbs.2020.02.003
Ramírez, E. S., Ruiz, F. J., Peña-Vargas, A., & Bernal, P. A. (2021). Empirical investigation of
the verbal cues involved in delivering experiential metaphors. International Journal of
Environmental Research and Public Health, 18(20), 10630.
https://doi.org/10.3390/ijerph182010630
Reid, J. E., Laws, K. R., Drummond, L., Vismara, M., Grancini, B., Mpavaenda, D., & Fineberg,
N. A. (2021). Cognitive behavioural therapy with exposure and response prevention in the
treatment of obsessive-compulsive disorder: A systematic review and meta-analysis of
randomised controlled trials. Comprehensive Psychiatry, 106, 152223.
https://doi.org/10.1016/j.comppsych.2021.152223
Rochefort, C., Baldwin, A. S., & Chmielewski, M. (2018). Experiential Avoidance: An
Examination of the Construct Validity of the AAQ-II and MEAQ. Behavior Therapy, 49(3),
435–449. https://doi.org/10.1016/j.beth.2017.08.008
Rolffs, J. L., Rogge, R. D., & Wilson, K. G. (2018). Disentangling components of flexibility via
the Hexaflex model: Development and validation of the Multidimensional Psychological
Flexibility Inventory (MPFI). Assessment, 25(4), 458–482.
https://doi.org/10.1177/1073191116645905
Ruiz, M. R., & Roche, B. (2007). Values and the scientific culture of behavior analysis. Behavior
Analyst, 30(1), 1–16. https://doi.org/10.1007/BF03392139
Sandoz, E. K., & Hebert, E. R. (2015). Meaningful, reminiscent, and evocative: An initial
examination of four methods of selecting idiographic values-relevant stimuli. Journal of
Contextual Behavioral Science, 4(4), 277–280. https://doi.org/10.1016/j.jcbs.2015.09.001
Schippers, M. C., Morisano, D., Locke, E. A., Scheepers, A. W. A., Latham, G. P., & de Jong, E.
M. (2020). Writing about personal goals and plans regardless of goal type boosts academic
performance. Contemporary Educational Psychology, 60, 101823.
https://doi.org/10.1016/j.cedpsych.2019.101823
Schippers, M. C., Scheepers, A. W. A., & Peterson, J. B. (2015). A scalable goal-setting
intervention closes both the gender and ethnic minority achievement gap. Palgrave
Communications, 1(1), 1–12. https://doi.org/10.1057/palcomms.2015.14
Schmitt, D. P., Long, A. E., McPhearson, A., O’Brien, K., Remmert, B., & Shah, S. H. (2017).
Personality and gender differences in global perspective. In International Journal of
Psychology (Vol. 52, pp. 45–56). Wiley-Blackwell Publishing Ltd.
https://doi.org/10.1002/ijop.12265
Schmitt, D. P., Realo, A., Voracek, M., & Allik, J. (2008). Why can’t a man be more like a
woman? Sex differences in Big Five personality traits across 55 cultures. Journal of
Personality and Social Psychology, 94(1), 168–182. https://doi.org/10.1037/0022-
3514.94.1.168
Schwartz, S. H., & Rubel-Lifschitz, T. (2009). Cross-national variation in the size of sex
differences in values: Effects of gender equality. Journal of Personality and Social
Psychology, 97(1), 171–185. https://doi.org/10.1037/a0015546
Sierra, M. A., Ruiz, F. J., Flórez, C. L., Hernández, D. R., & Soriano, M. C. L. (2016). The role
of common physical properties and augmental functions in metaphor effect. International
Journal of Psychology and Psychological Therapy, 16(1), 265–279.

Smith, K., & Hatemi, P. K. (2020). Are moral intuitions heritable? Human Nature, 31(4), 406–
420. https://doi.org/10.1007/s12110-020-09380-7
Smout, M., Davies, M., Burns, N., & Christie, A. (2013). Development of the Valuing
Questionnaire (VQ). Journal of Contextual Behavioral Science, 3(3), 164–172.
Sonntag, R., Wittchen, H. U., & Hoyer, J. (2017). Increasing valued behaviors precedes
reduction in suffering: Findings from a randomized controlled trial using ACT. Behaviour
Research and Therapy, 91, 64–71. https://doi.org/10.1016/j.brat.2017.01.013
Steele, D., & Hayes, S. C. (1991). Stimulus equivalence and arbitrarily applicable relational
responding. Journal of the Experimental Analysis of Behavior, 56(3), 519–555.
https://doi.org/10.1901/jeab.1991.56-519
Swift, V., & Peterson, J. B. (2019). Contextualization as a means to improve the predictive
validity of personality models. Personality and Individual Differences, 144, 153–163.
https://doi.org/10.1016/j.paid.2019.03.007
The Good Project. (2022). Value Sort. https://www.thegoodproject.org/value-sort
Thompson, M., Bond, F. W., & Lloyd, J. (2019). Preliminary psychometric properties of the
Everyday Psychological Inflexibility Checklist. Journal of Contextual Behavioral Science,
12, 243–252. https://doi.org/10.1016/j.jcbs.2018.08.004
Törneke, N. (2010). Learning RFT: An introduction to relational frame theory and its clinical
application. In Learning RFT: An introduction to Relational Frame Theory and its clinical
application.
Törneke, N., Luciano, C., Barnes-Holmes, Y., & Bond, F. W. (2015). RFT for Clinical Practice.
In The Wiley Handbook of Contextual Behavioral Science (pp. 254–272). John Wiley &
Sons, Ltd. https://doi.org/10.1002/9781118489857.ch12
Trindade, I. A., Ferreira, C., Pinto-Gouveia, J., & Nooren, L. (2016). Clarity of personal values
and committed action: Development of a shorter Engaged Living Scale. Journal of
Psychopathology and Behavioral Assessment, 38(2), 258–265.
https://doi.org/10.1007/s10862-015-9509-7
Trompetter, H. R., Ten Klooster, P. M., Schreurs, K. M. G., Fledderus, M., Westerhof, G. J., &
Bohlmeijer, E. T. (2013). Measuring values and committed action with the engaged living
scale (ELS): Psychometric evaluation in a nonclinical sample and a chronic pain sample.
Psychological Assessment, 25(4), 1235–1246. https://doi.org/10.1037/a0033813
Tyndall, I., Waldeck, D., Pancani, L., Whelan, R., Roche, B., & Dawson, D. L. (2019). The
Acceptance and Action Questionnaire-II (AAQ-II) as a measure of experiential avoidance:
Concerns over discriminant validity. Journal of Contextual Behavioral Science, 12(2), 278–
284. https://doi.org/10.1016/j.jcbs.2018.09.005
Vaughan-Johnston, T. I., Quickert, R. E., & MacDonald, T. K. (2017). Psychological flexibility
under fire: Testing the incremental validity of experiential avoidance. Personality and
Individual Differences, 105(1), 335–349. https://doi.org/10.1016/j.paid.2016.10.011
Villatte, M. (2018). Mastering the Clinical Conversation – using RFT to supercharge your
experiential practice. Contextual Consulting Website.
https://contextualconsulting.co.uk/workshop/mastering-the-clinical-conversation-using-rft-
to-supercharge-your-experiential-practice
Villatte, M. (2021). Mastering the Clinical Conversation: Online clinical RFT course.
https://matthieuvillatte.com/trainings-and-events/workshops/
Villatte, M., Monestès, J. L., McHugh, L., Freixa i Baqué, E., & Loas, G. (2010). Adopting the
perspective of another in belief attribution: Contribution of Relational Frame Theory to the
understanding of impairments in schizophrenia. Journal of Behavior Therapy and
Experimental Psychiatry, 41(2), 125–134. https://doi.org/10.1016/j.jbtep.2009.11.004
Villatte, M., Villatte, J. L., & Hayes, S. C. (2015). Mastering the clinical conversation:
Language as intervention. Guildford Publications.
Viskovich, S., Pakenham, K. I., & Fowler, J. A. (2021). A mixed-methods evaluation of
experiential intervention exercises for values and committed action from an Acceptance and
Commitment Therapy (ACT) mental health promotion program for university students.
Vukasovic, T. V., & Bratko, D. (2015). Heritability of personality: A meta-analysis of behavior
genetic studies. Psychological Bulletin, 141(4), 769–785.
https://doi.org/10.1037/bul0000017.supp
Wilson, K. G., & Sandoz, E. K. (2010). Mindfulness, values, and therapeutic relationship in
Acceptance and Commitment Therapy. Mindfulness and the Therapeutic Relationship, 89–
106.
Wilson, K. G., Sandoz, E. K., Kitchens, J., & Roberts, M. (2010). The valued living
questionnaire: Defining and measuring valued action within a behavioral framework.
Psychological Record, 6(1), 249–272. https://doi.org/10.1007/BF03395706
Wood, J. V, Perunovic, W. Q. E., & Lee, J. W. (2009). Positive self-statements: Power for some,
peril for others. Psychological Science, 20(7), 860–866. https://doi.org/10.1111/j.1467-
9280.2009.02370.x
 RFT is arguably not sufficiently well-supported and its links to ACT are tenuous
 Most studies of ACT’s core process have accidentally measured Neuroticism instead
 One cannot engage in valued action without having value clarity
 ACT’s underlying philosophy may negatively affect the therapeutic process

1 s2.0 S0005789422001022 Main

Uploaded by

Copyright:

Available Formats

1 s2.0 S0005789422001022 Main

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

1 s2.0 S0005789422001022 Main

Uploaded by

Copyright:

Available Formats

Journal Pre-proofs

ACT: A Process-Based Therapy in search of a process

Shane McLoughlin, Bryan T. Roche

To appear in: Behavior Therapy

Received Date: 21 June 2021

ACT: A Process-Based Therapy in search of a process

Corresponding author: Shane McLoughlin ([email protected]). This paper

Process-Based Therapy, the promise of which is to identify manipulable causal mediators of

instrumentalism, presenting several ethical challenges. We end by making several

research and therapy.

commitment therapy, mechanisms of action

ACT: A Process-Based Therapy in search of a process

Acceptance and Commitment Therapy (ACT; Hayes et al., 1999) is a third-wave

behavior therapy putatively comprised of multiple components. “Acceptance”, in ACT, refers to

worthwhile (facilitated using self-compassion, mindfulness etc.). In contrast, Cognitive

value-consistent behavior instead of efforts to reduce negative thoughts/emotions. In ACT,

as a by-product (see Sonntag et al., 2017).

Process-Based Therapy (PBT) refers to “contextually specific use of evidence-based

Relational Frame Theory (RFT; Hayes et al., 2001) is a behavior-analytic theory of

psychology (e.g., Barnes-Holmes et al., 2018).

Many Empirical RFT Studies are on Implicit Bias

RFT Findings Cannot Yet Be Generalized

Of course, RFT is arguably a promising theory of language and cognition, especially

single-subject investigations of symbolic relating behavior implicated in psychopathology or

for a relatively an unbiased accumulation of evidence for particular hypotheses.

Replication Issues and Publication Bias

(e.g., meta-analyses of the effect of specific technique X on specific outcome Y) to provide an

hypotheses derived from RFT.

Hulbert-Williams et al., 2020).

on RFT more broadly. For example, Hayes et al. (2021) say:

therapeutic relevance. Nonetheless, Clinical RFT is promoted to clinicians in workshops (e.g.,

2015) as a well-grounded approach to psychotherapy that harnesses an understanding of basic

relation to clinical efficacy).

Mismeasurement of the Core Process of ACT

expected factors without cross-loading to any significant degree). Next, a hierarchical

six hypothesized components of the Hexaflex.

6500+ Wrong Conclusions?

Advances in Measuring Psychological Flexibility

for not relating the items to meaningful life goals.

Another exception is the recently developed Personalized Psychological Flexibility Index

PF can be distinguished from negative emotion/neuroticism, both structurally and in terms of

particular respondent. It remains to be determined, therefore, whether this addition will be a

Jumping the Gun: No Valued Action Without Value Clarity

moral) identity is, as distinct from others’.

Value Clarity and Valued Action are Conflated

concept of valued action from value clarity.

The Utility of Values Exercises

positive self-statements (which might include statements of behavior/value alignment) can

efficacious for vulnerable people.

At present, there is some literature to support the benefits of including a values

component in psychological interventions, compared to not including such a component. In the

tolerance in cold-pressor tasks (Branstetter-Rost et al., 2009). In addition, within education,

appears to be the case across a range of different contexts.

Evidence-Based Value Clarification vs Naïve Realism

subsequently, far transfer towards valued action and wellbeing.

preferences/biases of therapists and clients are controlled for).

Measuring Valued Action: Talk is Cheap

can be inferred by functional analyses of past pro-environmental actions). Most measures of

direct observation of behavior that is a hallmark of radical behaviorism, the philosophical