164 Book Review
Book Review functional contextualistic a p p r o a c h to natural language.
S. C. Hayes, K. D. Strosahl,
& K. G. Wilson, Acceptance and
Commitment Therapy: An Experiential
Approach to Behavior Change
New York: Guilford Press (1999)
304 pp.
R e v i e w e d b y J a m e s D. H e r b e r t
MCP Hahnemann University
VERY SO OFTEN one has the distinct sense that a new
b o o k is d e s t i n e d to b e c o m e a classic. So it is with Ac-
ceptance and Commitment Therapyby Steve Hayes, Kirk Stro-
sahl, a n d Kelly Wilson.
Cognitive-behavioral a p p r o a c h e s to psychotherapy in-
creasingly d o m i n a t e the m e n t a l health field, at least
a m o n g those who espouse empiricism as a f u n d a m e n t a l
value in the d e v e l o p m e n t , evaluation, a n d dissemination
of behavior c h a n g e technologies. I n d e e d , it could be ar-
g u e d that since the publication o f Beck a n d colleagues'
Cognitive Therapy of Depression in 1979, the r e c e n t history
o f evidence-based psychotherapy has b e e n primarily
a b o u t the application o f cognitive-behavioral interven-
tions to an ever-growing range o f problems.
It is in this c o n t e x t that Hayes et al. p r e s e n t a very dif-
ferent m o d e l of psychotherapy that challenges some o f
the basic tenets that many cognitive-behavior therapists
have c o m e to accept, at least implicitly. T h e b o o k begins
by discussing the ubiquity o f h u m a n suffering, a n d sug-
gests that an u n d e r s t a n d i n g o f abstract l a n g u a g e - - a
uniquely h u m a n a c t i v i t y - - m a y h o l d critical clues to the
nature a n d e x t e n t o f this suffering. T h e philosophical
a n d theoretical f o u n d a t i o n s o f A c c e p t a n c e a n d Commit-
m e n t T h e r a p y (ACT) are t h e n presented. ACT was devel-
o p e d within the c o n t e x t o f a philosophical system known
as functional contextualism, r o o t e d in Skinner's radical
behaviorism, which emphasizes the relationship o f or-
ganisms to their e n v i r o n m e n t within a t h o r o u g h l y prag-
matic epistemology. T h a t is, the value o f a theory is n o t
d e t e r m i n e d by how accurately it maps the world, b u t
r a t h e r by how well the technology" that flows from the the-
ory permits "successful working" with respect to the
world.
Relational F r a m e T h e o r y (RFT) is then p r e s e n t e d as a
Cognitive and Behavioral Practice 9, 1 6 4 - 1 6 6 , 2002
1077-7229/02/164-16651.00/0
Copyright © 2002 by Association for Advancement of Behavior
Therapy. All rights of reproduction in any form reserved.
RFT builds u p o n concepts i n t r o d u c e d in Skinner's
(1957) VerbalBehavior; most notably the distinction be-
tween contingency-shaped behavior (that which is u n d e r
the control o f e n v i r o n m e n t a l contingencies o f reinforce-
ment) a n d rule-governed behavior (that which is u n d e r
the control o f verbal descriptions o f such contingencies).
RFT describes the processes by which verbal rules func-
tion to d o m i n a t e h u m a n behavior. In particular, Hayes et
al. argue that h u m a n language, while p e r m i t t i n g artistic
a n d technological achievements u n p a r a l l e l e d in the rest
o f the animal k i n g d o m , also has a d a r k side. A m o n g the
potentially negative consequences of language include
the t e n d e n c y for rule-governed behavior to be rigid a n d
inflexible in the face o f c h a n g i n g circumstances a n d to
interfere with direct behavioral contact with naturally oc-
curring e n v i r o n m e n t a l contingencies. L a n g u a g e also
forces contact with a wide range o f aversive thoughts a n d
feelings (e.g., self-criticism, imaginary negative conse-
quences), which in turn motivates various self-defeating
efforts to escape a n d avoid such aversive private events.
A c c o r d i n g to Hayes et al., the behavioral inflexibility
p r o d u c e d by verbal rules, in c o n c e r t with experiential
avoidance, underlies m u c h psychopathology. T h e au-
thors also argue that the n e e d to explain one's own be-
havior, an activity deeply r o o t e d in o u r sociolinguistic cul-
ture, also results in a variety of problems.
Based on this philosophical a n d theoretical founda-
tion, Hayes et al. focus the r e m a i n d e r o f the b o o k on de-
veloping ACT as an intervention. T h e a p p r o a c h is at once
familiar to those well-versed in cognitive behavior ther-
apy, a n d yet j a r r i n g l y different. T h e therapist begins by
fostering a sense o f "creative hopelessness," essentially
d e m o n s t r a t i n g that the client's various past attempts to
ameliorate his o r h e r p r o b l e m s have failed. It is e m p h a -
sized that this failure is n o t the result o f clients' n o t work-
ing h a r d enough, b u t instead on the futility o f the system
within which they were working. This initial step is be-
lieved to be i m p o r t a n t in laying the g r o u n d w o r k for a
new a p p r o a c h to conceptualizing the client's distress a n d
what to do a b o u t it. T h e n e x t phase o f t r e a t m e n t focuses
on h e l p i n g clients recognize the (often subtle) ways in
which they struggle to control their i n n e r lives, the futility
o f a t t e m p t i n g to do so, a n d the p r o b l e m s c r e a t e d by this
struggle. T h e pernicious role o f language in this process
is highlighted. Essentially, the m o d e l holds that the
source of distress is n o t negative private experiences p e r
se (including even such experiences as hallucinations o r
delusions), even t h o u g h b o t h the m a i n s t r e a m culture
a n d most schools of psychotherapy attribute distress pre-
cisely to such experiences. ACT instead holds that the
real p r o b l e m is the struggle to avoid, eliminate, or other-
wise control such experiences, c o m b i n e d with the idea
that such control is necessary as a p r e c u r s o r to resolving
 Book Review
problems and otherwise moving forward with one's cho-
sen goals. The process by which clients learn to distance
themselves from these negative experiences--without di-
rectly changing t h e m - - i s termed cognitive defusion.
Whereas traditional cognitive interventions focus on
changing the content of thoughts, the emphasis in ACT is
on changing the context in which thoughts (and other pri-
vate experiences) relate to behavior. The third broad
phase of treatment focuses on clarifying the client's
values. Global values are clarified and prioritized, and ef-
forts are made to translate such values into concrete goals
and corresponding directions for behavior change. The
final phase of treatment is the implementation of any
n u m b e r of more standard behavior therapy interventions
from within the ACT framework. Clients are asked to
make commitments to move toward behavioral changes
that are consistent with their chosen values.
Whereas Socratic dialogues are the primary therapeu-
tic tools of prototypical cognitive therapy, the m e t a p h o r
is the sine qua n o n of ACT. The b o o k is rich with meta-
phors. Since a primary goal of ACT is to u n d e r c u t de-
structive rule-governed behavior, the approach hesitates
to use rules (in the form of direct instructions), and in-
stead relies heavily on metaphors, many of which are par-
adoxical, in order to make critical points.
The book concludes with a chapter on the therapeutic
relationship in ACT, m u c h of which will be familiar to
cognitive behavior therapists. The egalitarian, consulta-
tive posture of the therapist is emphasized, as well as the
importance of the therapist's self-understanding from
within the ACT model. The final chapter focuses on in-
teresting speculations about the role of the scientific
analysis o f language in addressing many of the problems
facing h u m a n k i n d in the 21st century.
This work has many noteworthy strengths. Arguably, it
represents one of the few truly unique contributions to
the field of psychotherapy in quite some time. At a tech-
nical level, m u c h o f the material will be familiar to most
experienced psychotherapists. ACT draws heavily from
cognitive behavior, existential/humanistic, and Gestalt
approaches to therapy in particular, as well as certain
Eastern (especially Buddhist) traditions. Its uniqueness
stems not so m u c h from new techniques (although many
o f the metaphors are in fact novel and unique to ACT),
but from the philosophical and theoretical framework
within which these techniques are embedded. A n o t h e r
strength is that the approach is presented as a general
blueprint rather than a rigid prescription of techniques.
This stands in stark contrast to the growing n u m b e r of
trademarked, proprietary therapies in which training is
stricdy controlled by proponents and strict adherence to
the minutiae of protocol is d e m a n d e d (Herbert et al.,
2000). In fact, reflecting the true spirit of science, Hayes
et al. actively invite the reader to experiment with, m o d -
165
ify, and continue to develop the strategies developed in
the book. O n a related theme, although clearly excited
and optimistic about ACT's potential, the authors are
careful to avoid overstating their case for its effectiveness
before m o r e controlled data are collected. Although data
on the effectiveness of ACT are limited, the few studies
that have been conducted are quite promising. From a
practical standpoint, ACT provides a potentially useful
approach to working with especially difficult clients, in-
cluding those for w h o m established treatments have
failed.
Despite these many strengths, the b o o k is not without
its problems. P a r a m o u n t a m o n g these is that it comes
dangerously close to violating the connectivity principle
in science. Truly innovative theories not only account for
new data that have stretched the explanatory limits of ex-
tant theories, but they also must explain existing data.
Hayes et al. emphasize ACT's differences with "standard"
cognitive therapies so m u c h that they fail to account for
the many successes of such therapies over the past 2 de-
cades. For example, a frequent theme t h r o u g h o u t the
b o o k is the often pernicious effects of verbal rules, and
the need for therapeutic principles that u n d e r c u t such
rules in favor o f direct contact with environmental con-
tingencies of reinforcement. How, then, do we account
for the success of approaches that could be described as
heavily d e p e n d e n t on the provision of just such rules? If
one knew nothing about standard cognitive therapy be-
fore reading this book, one might conclude that such an
approach would be destined to fail miserably. The prob-
lem is that it does not. Hayes et al. do not sufficiently ad-
dress the successes of cognitive therapy within the con-
text of ACT.
A related problem concerns self-generated rules.
Given their strong motivation to make sense of their
world, humans are constantly generating rules (which
may or may not be accurate or useful), which in turn
come to influence their behavior. Although Hayes et al.
decry the negative psychological effects of m u c h rule-
governed behavior, it is n o t clear that we can avoid gener-
ating rules, even if we try. For example, a client under-
going ACT might develop a rule such as, "I can move
forward toward my goals better if I accept my negative
thoughts and feelings rather than trying to change them."
So while Hayes et al. may aim to u n d e r c u t rule following,
they may instead be encouraging the development o f
new (and presumably more productive) rules. If this is in
fact true, then it remains to be seen if simply providing
such rules directly, rather than having clients discover
them for themselves, really makes a difference.
After developing the ACT framework for psychother-
apy, Hayes et al. suggest that most any established strategy
from behavior therapy (e.g., exposure therapy, social
skills training) can be used, provided it is presented
166 Book Review
within the ACT context. Unfortunately, they state that ex-
plication o f this integration is "beyond the scope" o f the
book. A l t h o u g h the integration o f certain techniques
(e.g., exposure-based strategies for phobias) within ACT
would a p p e a r to be relatively straightforward, such inte-
gration is less obvious for o t h e r strategies, especially
those relying on verbal instruction. A l t h o u g h an ade-
quate t r e a t m e n t o f such integration would p r o b a b l y re-
quire a n o t h e r book, some f u r t h e r discussion o f such inte-
gration would have m a d e this work m o r e useful for the
practicing clinician. Moreover, the fact that ACT can be
so readily i n t e g r a t e d with traditional behavior therapy
strategies poses the p r o b l e m o f d e m o n s t r a t i n g additive
benefits o f the ACT framework above a n d b e y o n d the ef-
fects o f established techniques. If an established treat-
m e n t is used within ACT to p r o d u c e g o o d results, one
must be careful to avoid attributing the effects to ACT
without p r o p e r e x p e r i m e n t a l controls.
T h e b o o k ' s overall style is b o t h a strength a n d a weak-
ness. As is typical o f these authors, the ideas p r e s e n t e d
are unusually sophisticated a n d t h o u g h t provoking. Nev-
ertheless, there are two places in which the writing may
weaken the overall message. T h e first is in the discussion
o f functional contextualism in c h a p t e r 2. Clinicians who
are n o t already versed in p h i l o s o p h y a n d / o r who are n o t
especially interested in philosophical pursuits may find
this c h a p t e r difficult to follow. T h e s e c o n d drawback con-
cerns the case descriptions. A l t h o u g h the f r e q u e n t use o f
case material is helpful in illustrating various ACT strate-
gies, most o f the clients s o u n d as if they have Ph.D.s in
psychology or philosophy! It would have b e e n m o r e help-
ful to describe dialogues with less educated, less psycho-
logically m i n d e d clients that m a n y therapists are m o r e
likely to e n c o u n t e r routinely.
O n e c o u l d take issues with o t h e r tenets o f ACT as
well, such as the c o m p l e t e rejection o f theoretical corre-
s p o n d e n c e in favor o f "successful working" as the episte-
m o l o g y o f the a u t h o r s ' f u n c t i o n a l c o n t e x t u a l i s m (see
Erwin, 1997, for an interesting critique). T h e r e is also the
slightly dishonest claim that the therapist "doesn't know"
when asked by clients in the initial phase o f t r e a t m e n t
what is b e i n g r e c o m m e n d e d in lieu o f failed p r i o r at-
tempts to change. But p a r t o f what makes this such an ex-
citing b o o k is that it raises so m a n y interesting questions,
r a t h e r than offering simplistic answers to stale questions.
Like the therapy it describes, the real strength o f this fas-
cinating b o o k is the challenge it presents to the r e a d e r to
grapple with a variety o f philosophical, theoretical, a n d
technical issues. Acceptance and Commitment Therapy is a
must read.
References
Beck, A. T., Rush, A.J., Shaw;B. E, & Emery, G. (1979). Cognitivetherapy
of depression. New York: Guilford Press.
Erwin, E. (1997). Philosophy and psychotherapy:Razisg the troublesof the
brain. London: Sage.
Herbert, J. D., Lilienfeld, S. O., Lohr, J. M., Montgomery, R. W.,
O'Donohue, W. T., Rosen, G. M., & Tolin, D. E (2000). Science
and pseudoscience in the development of Eye Movement Desen-
sitization and Reprocessing: Implications for clinical psychology.
Clinical PsychologyReview, 20, 945-971.
Skinner, B. E (1957). Verbal behavior. New York: Appleton-Century-
Crofts.