Abstract
The central question of this article is whether Cognitive Behavioral Therapy (CBT) and its so-called “third wave” derivatives represent genuine progress in the field of psychotherapy. Despite the technical complexity of classical CBT, which comprises cognitive restructuring, behavioral experiments, and various coping skills, there is considerable uncertainty about which components are actually effective. There is considerable evidence that cognitive interventions do not add any additional benefit to behavioral techniques such as exposure to anxiety stimuli or behavioral activation.
Approaches collectively referred to as the third wave, such as Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT), and Mindfulness-Based Cognitive Therapy (MBCT), have developed an increasingly abstract terminology adorned with philosophical concepts. Most of the concepts these approaches offer, such as “acceptance,” “mindfulness,” and “dialectics,” are not new; they are merely relabelings of existing knowledge. The concept of “acceptance” is directly affected by the problems of moral relativism and a-moral instrumentalism inherent in the pragmatist philosophy on which it rests. Pragmatism’s principle that “the truth of an idea is determined by its workability” replaces universal moral principles with a criterion of “whether it works or not.” This understanding leaves the question “for whom does a given action or situation work?” unanswered. A practice that serves the interests of the powerful can be considered legitimate from a pragmatist perspective as long as it “works” within that system. Many morally unacceptable practices, such as systematic oppression, poverty, injustice, discrimination, slavery, wars waged in the name of “national interests” that bring disaster to millions, torture and other human rights violations, can “work” in certain contexts. Pragmatist philosophy possesses no internal moral principles that would encourage people to oppose such practices. This philosophy poses a serious problem in many respects for approaches that place “acceptance” at the center of psychotherapy. Moreover, considering that there is no evidence that these therapies are superior to CBT in terms of outcomes, there is no logical justification for preferring them.
An intervention (Control‑Focused Behavioral Treatment -CFBT) that we have been developing since the 1990s offers a viable alternative to other therapies in many respects. This treatment is based on a robust learning theory that posits that traumatic stress arises from the perceived unpredictability and uncontrollability of the traumatic events experienced. It focuses solely on avoidance behaviors and includes no systematic cognitive interventions. The goal is not to reduce anxiety but to enable the person to confront anxiety‑provoking stimuli in their natural environment, thereby increasing their sense of control over those stimuli and enhancing their resilience to stress. Because we have observed that many people spontaneously recover using this method on their own after mass disasters, this “natural recovery process” likely has evolutionary underpinnings. Indeed, findings from ethology and evolutionary psychology show that when avoidance behaviors interfere with vital functions, they are abandoned even at the risk of life‑threatening danger. CFBT has been modeled after this natural recovery process.
Our meta‑analytic findings show that CFBT achieves recovery rates of 80‑90% in trauma survivors after just 1‑2 sessions, whereas other lengthier, evidence‑based treatments achieve around 50% recovery. The universal nature of the treatment’s core theoretical principles and its relative ease of application enhance its cross‑cultural applicability. In addition, the largely self-administered nature of the intervention makes it possible to deliver it to large populations in mass disaster settings. In conclusion, progress in psychotherapy lies not in developing increasingly complex theories and techniques, but in employing the healing capacities inherent in human nature in the simplest and most effective way.
Keywords: Cognitive Behavioral Therapy, third‑wave therapies, Control‑Focused Behavioral Treatment, CFBT, ACT, DBT, MBCT, progress in psychotherapy, natural recovery, sense of control, acceptance, moral problems
INTRODUCTION
The so-called cognitive revolution spearheaded by Aaron T. Beck In the 1970s gained momentum in the 1980s and 1990s, leading to the development of Cognitive Behavioral Therapy (CBT), an approach used in the treatment of many conditions, including depression and anxiety disorders. Following traditional Behavior Therapy (BT), CBT was succeeded by what are termed “third wave” psychotherapies, such as Mindfulness Based Cognitive Therapy (MBCT), Dialectical Behavior Therapy (DBT), and Acceptance and Commitment Therapy (ACT). Since the 1990s, there has been a growing interest in these therapeutic approaches in Western countries, a phenomenon that has also been reflected in developing countries such as Türkiye.
As a researcher who has worked in the field of psychotherapy, particularly behavioral psychotherapy, for over 50 years, I have previously expressed in my blog posts my criticisms regarding the uncritical import and application of psychotherapy models originating from Western countries to Türkiye. I have written this article with a view to contributing to the field of mental health in Türkiye and other developing countries, especially to the new generation of mental health professionals who are in search of better approaches in psychotherapy, by offering a critical and more realistic perspective on cognitive and behavioral therapies. I do not aim to provide a comprehensive review of the literature on CBT and its newer derivatives here. I will only examine the theoretical and conceptual problems of these therapeutic approaches and their cross cultural applicability.
COGNITIVE BEHAVIORAL THERAPY
CBT is a broad approach in which many therapy techniques are used in various combinations. Among the techniques frequently used in recent years are cognitive restructuring, imaginal or live exposure to feared situations, relaxation training, meditation, coping skills training, problem solving, social skills training, breathing retraining, thought stopping, guided self dialogue, behavioral activation, and other operant conditioning techniques aimed at changing problematic behavior using reward/punishment stimuli. For this reason, although nearly half a century has passed since the emergence of the therapy and hundreds of studies have been conducted on it, the question “What is CBT?” is still being asked (e.g., Wampold et al., 2017). Furthermore lack of consensus on this issue and contradictory definitions in meta analytic studies that aim to compare the effectiveness of the therapy with other treatments reduce the reliability of these studies and make it difficult to reach a definitive conclusion.
Effectiveness Compared to Other Treatments
Since Freud, many psychotherapy methods have been proposed, and the question of which method is superior to others has remained a subject of intense debate to date. Today, there are more than 400 psychotherapy approaches, and their proponents typically show efforts to protect their own territory. Dattilio and Norcross (2006) define this behavior as “instinctual territoriality,” a concept that has later been examined in the context of the “allegiance effect” (e.g., Munder et al., 2019; Lilienfeld, 2017). Until the 1950s, the debates on this issue were at the level of theoretical observations or observations related to individual cases; later, they were based on empirical evidence, and meta analytic methods were developed to compare the results of the growing number of studies.
CBT is one of the most researched approaches among psychotherapies. Accordingly, in the last 20 years, many meta analytic studies on CBT research and many literature reviews on these studies have been published. We see that these studies do not report consistent and universally acceptable results regarding whether CBT is more effective than other psychotherapies. For example, meta analytic studies conducted in recent years that concluded that CBT is more effective (Marcus et al., 2014; Mayo Wilson et al., 2014; Tolin, 2010; Tolin, 2014) have been criticized by Wampold and colleagues (2017) on four important methodological grounds: (1) effect size, sample size, and level of statistical significance; (2) evaluating outcomes only on some disorder specific symptoms and neglecting scales that reflect the patient’s general psychological state; (3) problems and inconsistencies in the classification of treatment protocols used in the examined studies; (4) inclusion of problematic and biased studies in the analysis and exclusion of studies that do not show superiority of CBT. Similar methodological criticisms have continued in more recent studies (e.g., Flückiger et al., 2022; Cuijpers et al., 2020). Considering these methodological problems, it has been concluded that CBT shows small, often statistically non significant differences compared to other treatments, limited to certain disorder symptoms, or differences arising from methodologically flawed studies included in the analysis.
It is worthwhile to dwell a little longer on this article by Wampold and colleagues because it contains some interesting information. For example, one of the meta analytic studies examined by these authors (Tolin, 2010) was conducted by a research group that included David Clark, one of the pioneers of CBT. This study included a clinical trial published by Clark and colleagues in 2006 comparing CBT with “Applied Relaxation” developed by Öst (Öst, 1987) in social phobias (Clark et al., 2006). Regarding this study, which they found problematic, Wampold and colleagues ask why Clark and colleagues chose Öst’s treatment (and moreover modified the original protocol of the treatment in a way that would reduce its effectiveness) for comparison with CBT, when there is an exposure therapy whose effectiveness has been shown by numerous studies. In their 2006 article, Clark and colleagues stated that they preferred “Applied Relaxation” because it led to a lower rate of early treatment drop out than standard exposure therapy, and they defended this choice by referencing the findings of another study they conducted in 1994 with the same treatments (Clark et al., 1994). Here, Wampold and colleagues raise two questions: (1) When referencing the 1994 study, why did you not mention the finding that “Applied Relaxation” had no effect at all? (2) Why did you choose a treatment that you knew was ineffective to compare with CBT? From the same article, we understand that another controlled study conducted by Clark and colleagues with CBT, although unpublished, was included in the meta analytic study in which Clark himself participated, that an unusually large treatment effect (d = 1.63) was found in this study, and that Wampold and colleagues wanted to examine this unpublished article, but Clark refused. In conclusion, Wampold and colleagues state that the meta analytic studies they examined were biased, that this approach reduces the reliability of the results, but that it would not be right to look for intent in these biases. Although I agree with this view, , we understand from this article (worth reading by everyone concerned) how some meta analytic studies that determine health policies in the Western world are conducted. Over the years, I have personally witnessed many other practices in clinical research, including drug studies, that have nothing to do with science and serve personal (or institutional) interests, so I felt the need to mention this example here to emphasize that the results of all kinds of research should be approached cautiously and critically.
When meta analytic studies examining the effects of CBT compared to control groups are carefully examined, we sometimes see inconsistencies between the data obtained and the conclusions reached. It can be said that these inconsistencies largely stem from the personal preferences of the researchers conducting the studies or their biased behavior for various reasons. For example, in a review by Hofmann and colleagues (Hofmann et al., 2012) of 106 meta analytic studies covering a wide range of psychiatric disorders (including substance abuse, schizophrenia and other psychotic disorders, depression and dysthymia, bipolar disorder, anxiety disorders, somatoform disorders, eating disorders, insomnia, personality disorders, anger and aggression, criminal behavior, general stress, stress conditions caused by medical illnesses or pregnancy complications, and some problems seen in children and the elderly), we see that findings showing CBT to be effective compared to a control group pertain only to a few of the many disorders studied (anxiety disorders, somatoform disorders, bulimia, anger control problems, and general stress). Nevertheless, the authors concluded that the evidence base of CBT is “generally very strong.” Immediately after this statement, they say, “However, additional controlled studies are needed to examine the effectiveness of CBT” (p. 1). It is difficult to reconcile these two statements. [More recent meta analytic reviews also exhibit a similar contradiction (e.g., Cuijpers et al., 2021). For Hofmann’s response to these criticisms, see his 2021 article (Hofmann, 2021).] The authors also mention that insufficient studies have been conducted on ethnic minority and low income groups.
Meta analytic studies on trauma treatment have also led to controversies regarding their methodology and results. Bradley and colleagues (2005) found no difference between exposure therapy, CBT, exposure therapy + CBT, and EMDR (Eye Movement Desensitization and Reprocessing) in a meta analytic study. More recent systematic reviews and network meta analyses have reached similar results but have also shown small differences between some treatments (e.g., Mavranezouli et al., 2020; Forman Hoffman et al., 2018). Two other studies (Benish et al., 2008; Cloitre, 2009) obtained the same results, but the 2008 study was methodologically criticized by other researchers in a study (Tran & Gregor, 2016), and after the errors were corrected, it was reported that the results showed that exposure therapy is slightly more effective than other treatments, including CBT. A more recent meta analysis (McLean et al., 2022) also supports the superiority of exposure therapy.
In conclusion, although there is evidence that CBT is effective for some disorders, whether it is superior to other bona fide treatments has not yet been fully clarified. [For current meta analyses supporting the “Dodo bird” view that psychotherapies are generally equivalent, see Baardseth et al., 2018; Cuijpers et al., 2019.] This is an extremely important issue, because if it really has no superiority as claimed, this means that the improvement observed in treatment does not originate from the cognitive processes or mechanisms that are claimed to be specific to the treatment. At this point, let us briefly look at what these mechanisms are.
Theoretical Basis and Mechanisms of Action
I have previously stated that CBT is an approach consisting of many techniques. To what extent and through which mechanisms these techniques contribute to the therapeutic effect is not sufficiently known. A current systematic review on this subject (Kazantzis et al., 2018) examined the contribution of different techniques of CBT to effect sizes and showed that the evidence is still limited. The cognitive restructuring technique of the therapy aims to eliminate distress or fear by modifying thoughts and beliefs that cause distress or fear and are often characterized by catastrophic expectations. To facilitate the modification of these thoughts, the patient is advised to conduct some “behavioral experiments” (e.g., “do not escape or avoid a situation you fear and see for yourself whether the fear you will experience is realistic”). Here, the element with the potential to be effective is not the cognitive interventions performed before the “behavioral experiments”, as believed in some circles, but the experiments themselves. In other words, without actually facing the fear, it is unlikely that a change only in problematic thoughts or beliefs will reduce or eliminate distress or fear. This is because, in conditions such as phobias, obsessive compulsive disorder, and PTSD, fear emerges due to classical conditioning processes, and therefore, cognitive control over these fears is not possible (Mineka & Zinbarg, 2006; Krypotos et al., 2015). Indeed, many phobic patients express this when told that their fears are unrealistic by saying, “I know my fear is absurd, but I can’t help feeling afraid.” Although the opposite can be argued theoretically, there is no credible evidence to support this view, because none of the studies conducted with CBT have used a methodology that would show that the observed improvement resulted from cognitive change without behavioral change. This issue has also been raised by others (e.g., Teachman et al., 2019). To demonstrate this, we need “prospective” studies that examine in detail the chronological order of changes in the patient’s thoughts, emotions, and behaviors between therapy sessions and show that improvement occurs before behavioral change. Such studies have not been conducted. Lemmens et al. (2016) also identified the lack of such prospective mechanism studies as a general problem for psychotherapy research. Cognitive interventions may only have a motivational effect on facing fears, and the improvement attributed to cognitive change by the therapist may well have resulted from the patient facing the feared situation between sessions. Furthermore, we know that many trauma survivors, unable to endure the negative impact of the distress or fear they experience in their natural environment on their lives, abandon their avoidance behaviors and recover by facing their fears without any therapist help (Başoğlu et al., 2011). Such “natural recovery” processes also show that a cognitive intervention is not necessary for recovery to occur; the important phenomenon is behavioral change.
One of the most important problems of cognitive theory is that it is based on the unproven assumption of a cause and effect relationship between “unrealistic” thoughts and beliefs and problems such as anxiety disorders or depression. Negative cognitions may very well be a result or a symptom of these disorders. For this reason, significant criticisms of the approach have emerged from within the CBT community in the last 20 years (Hayes et al., 2006; Longmore & Worrell, 2007; Gaudiano, 2006; Hofmann & Hayes, 2019). An important study investigating what is effective in CBT was conducted by Jacobson and colleagues (1996). In a study comparing CBT for depression with “Behavioral Activation” therapy, which contained no cognitive intervention and aimed to remedy the inability to perform daily activities caused by depressed mood and to help the person regain the behaviors that would allow them to return to their normal life, these researchers observed no difference between the two approaches and observed that cognitive changes emerged after behavioral therapy. It has also been shown in other studies that behavior therapy leads to cognitive changes (Foa et al., 1999; Foa & Rauch, 2004; Livanou et al., 2002). Other researchers have also shown that behavioral activation is as effective as CBT and that cognitive interventions do not add extra benefit (Richards et al., 2016; Cuijpers et al., 2021). In their systematic review on this subject, Lorenzo Luaces et al. (2021) stated that the evidence for the necessity of cognitive restructuring in depression is weak. Another study (Burns & Spangler, 2001) failed to obtain findings confirming the assumed causal relationship between “faulty” thoughts and beliefs and treatment outcome in 521 cases treated with CBT. These findings are consistent with evidence that cognitive interventions (Jacobson et al., 1996; Marks et al., 1998; Paunovic & Öst, 2001) or coping skills techniques (Jacobson et al., 1996; Foa et al., 1991) do not add extra benefit to treatment when used together with exposure treatment.
Data from our own studies are consistent with these findings. For example, in a comparative study we conducted with 1,358 individuals exposed to war and torture trauma in former Yugoslavia and 519 control participants who had not experienced any trauma (Başoğlu et al., 2005), we observed that the thoughts and beliefs of trauma survivors showed statistically significant changes compared to the control group, albeit not large, but we found no strong relationship between these cognitive changes and Post Traumatic Stress Disorder (PTSD) or depression. This finding supports the view that there is no causal relationship between trauma induced cognitive changes and PTSD and depression. Furthermore, the high recovery rates we observed in our studies with Control Focused Behavioral Treatment (CFBT), which focuses only on avoidance behaviors and does not involve systematic cognitive interventions (Başoğlu et al., 2003a; Başoğlu et al., 2003b; Başoğlu et al., 2005; Başoğlu et al., 2007; Başoğlu, 2022), clearly show that cognitive interventions are not necessary in treatment.
Another criticism of CBT (Gaudiano, 2008) is that the therapy was developed in clinical settings in the 1970s and did not sufficiently take into account the findings of experimental cognitive psychology that began to emerge around the same years. Referring to the title of an article (“Is it necessary to change thoughts in cognitive behavioral therapy?”) by Longmore & Worrell (2007), Gaudiano notes in the same article that it is interesting that such a question is raised after 325 studies on CBT. This is indeed an interesting phenomenon that deserves reflection. At this point, I cannot help but mention an anecdote that I find interesting. In the 1990s, when CBT was being promoted as a “cognitive revolution” and gaining popularity (and I had the opportunity to observe this process closely while working in England), we published letters (to the editor) questioning the validity of the results of a study by David Clark and colleagues on the cognitive behavioral treatment of Panic Disorder and Agoraphobia published in the British Journal of Psychiatry (Marks et al., 1994; 1995). In these letters, we pointed out that the methodology used in Clark and colleagues’ treatment study did not allow for the observed improvement at the end of treatment to be attributed to cognitive interventions and that this improvement could also have resulted from the behavioral components of the treatment (i.e. exposure), implying that cognitive interventions might be unnecessary. In their responses to these letters (Clark et al., 1994, 1995), the researchers, while defending their study vehemently in response to other comments, had to accept this criticism and stated that new studies investigating the independent effects of different components of the treatment were needed. Interestingly, 11 years after these debates, in a later article, Clark and colleagues (2006) concluded in their review of the literature that “comparative studies to date have not found credible differences between behavior therapy involving exposure and established CBT programs.” Nevertheless, as also noted by Rosenfield and colleagues (2018), no study has been conducted to date to tease out the critical ingredients of CBT from the redundant elements (which can be achieved by using prospective research designs, as noted earlier). Nonetheless, CBT (and its derivatives) have continued to gain popularity in many countries and survived to this day.
The cause and effect relationship assumed by cognitive theory between “faulty” thoughts and various stress responses such as distress or depression, implicitly shifts the responsibility for these problems to the patient and leads to the neglect of the relationship between the stressor and the stress response, a relationship that is independent of individual specific characteristics. We see this effect-response relationship most clearly (or largely independent of the effects of intervening variables) in traumatic events, especially torture trauma. We know from our studies (Başoğlu et al., 1994a, 1994b, 1995, 1996, 1997) that people who are psychologically prepared for torture due to their previous life experiences (e.g., political activity) are less affected by torture. However, these same studies show that even in these people, traumatic stress symptoms can emerge, albeit less frequently. This finding shows us that there is a relationship, even if not linear, between the severity of the stressor and stress responses. Therefore, the fact that stressors stemming from living conditions can lead to stress effects such as distress and depression independently of thought and belief characteristics should not be ignored.
Application Problems
Having originated from the middle social class of Western countries, CBT reflects the cultural values, socio‑economic conditions, educational level, and ideological position of that class. One of the best examples of this is that the main goal of therapy has been adopted as the elimination of anxiety. This reflects a puritanistic understanding of happiness as a lifestyle free from all kinds of anxiety and distress. This is indeed one of the reasons why companies that produce tranquilizers and antidepressant drugs find such a large market in these countries. This understanding has reached a stage where a “trigger warning” is placed as a measure of protection at the beginning of all kinds of written and visual publications (and even lessons given in schools) that describe or remind people of traumatic events experienced by others.
This theoretical problem of CBT limits its applicability, especially in trauma treatment. Not all anxiety-evoking thoughts and beliefs that emerge after trauma or fear are unrealistic or irrational. This is particularly true for situations where the same trauma is experienced repeatedly, or at least the probability of recurrence is high. Examples include earthquakes, war, and torture. In such cases, the fear experienced does not stem from exaggerated “catastrophic” expectations or thoughts. The fear felt in trauma environments that pose a real threat to life is natural and it is neither possible nor necessary to reduce it. Such situations pose a serious problem for psychotherapies that aim to reduce or eliminate distress, such as traditional BT and CBT.
Like many other psychotherapy models, CBT has application problems in different cultures, races, ethnic groups, and social classes (Satterfield, 1998). How to overcome these problems has not been sufficiently researched (Hinton & Patel, 2017). For cognitive therapy to be performed, the person needs a certain level of cognitive differentiation, the ability to think in abstract terms, and a capacity for introspection. A review examining the applicability of CBT in populations with low educational levels (van der Heiden et al., 2021) emphasized that individuals in this group have difficulty with abstract cognitive interventions. It suggested that more concrete, behavior‑focused approaches should be preferred. Furthermore, the symptoms of conditions such as anxiety disorders and depression show differences across cultures and social classes. For example, in Turkey, depressive patients who present for treatment often express distress with somatic symptoms (Başoğlu, 1984; Uluşahin et al., 1994). Also, it is not uncommon for some psychiatric disorders to be attributed to “possession by jinns” or being “put under a spell” by someone. Clearly, difficulties will be encountered in applying cognitive therapy to such patients coming from rural areas with low education levels. This problem has not been adequately resolved (Rathod et al., 2018).
One of the important application problems of CBT is the duration of treatment. Although this treatment is usually given in 10‑15 sessions and is characterized as short‑term compared to some other psychotherapies, it still brings a significant cost. Furthermore, there are difficulties in delivering it to the large number of people who may need treatment after mass disasters such as earthquakes and war. Since CBT involves techniques that often require a skilled therapist to administer, it is suitable for self-administration. Indeed, two studies aimed at effectively delivering the treatment with “self‑help” booklets ended in failure (Ehlers et al., 2003; Scholes et al., 2007). A more recent meta‑analysis supporting these findings (Cuijpers et al., 2019) showed that the effect size of CBT when delivered without therapist support is very small. It also showed that completely self‑administered programs are not sufficient on their own in mass disasters.
Although there are studies showing that internet‑based CBT is effective in recent years, most of these studies are uncontrolled studies conducted with small groups (Kumar et al., 2017). Moreover, the treatment programs used in these studies are not designed to require no involvement, help, or contribution from the therapist – that is, they are not programs that the person can apply entirely on their own. Their purpose is rather to deliver the treatment remotely and more economically by reducing therapist time. A comprehensive meta‑analysis examining the effectiveness of therapist‑assisted internet‑based CBT (Karyotaki et al., 2021) revealed that such programs are effective for mild to moderate depression. However, the effect significantly decreases when therapist support is completely removed. This finding shows that there are still serious obstacles to the widespread use of completely self‑administered CBT in mass disasters.
To summarize the issues discussed so far, the problems of CBT can be grouped under four main headings: (1) the assumed causal relationship between cognition and behavior; (2) the goal of reducing or eliminating distress or fear; (3) potential problems in cross‑cultural and cross‑social class applicability; and (4) the lack of sufficient evidence that it can be widely delivered to masses using “self‑help” principles without any help or contribution from the therapist. It can be said that the first two problems of CBT played an important role in the emergence of its derivatives such as MBCT, ACT, and DBT. At this point, let us briefly review how these therapies differ from CBT in terms of their goals and presumed mechanisms of action. As other CBT derivatives such as “meta‑cognitive therapy,” “rational‑emotive behavior therapy,” “cognitive processing therapy,” “cognitive‑behavioral analysis system of psychotherapy,” and “schema‑focused therapy” share common features with CBT in their basic theories, goals, and presumed mechanisms of action, I will not discuss each of them separately.
“THIRD WAVE” COGNITIVE AND BEHAVIORAL THERAPIES
Although CBT, MBCT, ACT, and DBT are similar in involving various cognitive and behavioral approaches, they differ in terms of the techniques they utilize, their objectives, and their presumed mechanisms of action. A comprehensive meta‑analysis examining these differences (Hofmann et al., 2021) suggested that although “third‑wave” therapies show stronger effects than traditional CBT on transdiagnostic targets such as emotion regulation and psychological flexibility, they are not more effective than CBT for anxiety and depression.
Unlike CBT, these therapies do not aim to reduce anxiety by changing distressing thoughts and beliefs. Instead, they aim to reduce the impact of thoughts on behavior by enabling the person to distance themselves from those thoughts and to observe them from the outside. To give an example, it is thought that such a change could be achieved by enabling the person to see a thought like “I am a worthless person” as “I am having the thought that I am a worthless person.” This is not a new technique. It was first defined as a logotherapy method (“paradoxical intention”) by Frankl (1959), later described as “cognitive distancing” in the 1980s by Beck et al. (1985).
This method also forms the essence of Metacognitive Therapy (MCT) developed by Wells (1995). However, in MCT, the goal of changing thoughts is still maintained. A network meta‑analysis on the effects of MCT (Normann et al., 2019) showed that MCT had higher effect sizes than CBT in the treatment of anxiety and depression, but this difference decreased in follow‑up measurements.
In MBCT, developed by Teasdale and colleagues (2000), the goal of the therapy is more about increasing the individual’s awareness of their thoughts and emotions. The aim is to help the person see them not as phenomena that always reflect reality and are part of the self, but merely as “mental processes.” What MBCT, ACT, and DBT have in common is that they use the technique of “mindfulness” to achieve such a “metacognitive” change. Mindfulness originates from the Buddhist philosophy of the Far East (Kabat‑Zinn, 1994).
A systematic review examining the mechanisms of action of these therapies (Gu et al., 2015) stated that the main function of these techniques is to provide “cognitive defusion” through mindfulness. However, it is still controversial whether this process offers as strong a mechanism of change as behavioral activation or exposure treatment. This finding suggests that the effect size of the therapy may be limited. Indeed, the findings of a meta‑analytic comparison I conducted on the effects of trauma treatments are consistent with this view.
Similarly, one of the most comprehensive meta‑analyses conducted on this subject (Goldberg et al., 2018) showed that mindfulness‑based interventions are moderately effective for anxiety, depression, and stress‑related problems. However, effect sizes diminish over time. Moreover, the authors emphasized that although these effects cannot be largely reduced to placebo or expectancy effects, this therapy cannot replace traditional behavioral therapies.
Acceptance and Commitment Therapy (ACT)
ACT was developed by Hayes and colleagues in the 1980s and 1990s (Hayes et al., 1999). It is said to be based on a philosophical view called “Functional Contextualism” and “Relational Frame Theory” (RFT). According to information provided on the website of the Association for Contextual Behavioral Science (ACBS), Functional Contextualism has its origins in the philosophical views of Stephen Pepper (Pepper, 1942). According to Pepper, philosophical approaches to understanding the world consist of several “world hypotheses” or “worldviews.” Underlying each worldview is a “root metaphor” and a “truth criterion.” Root metaphors are based on everyday objects or ideas that are apparently well‑understood and commonsensical. They serve as a “basic analogy” that helps the individual in their efforts to understand the world. Truth criteria are inseparably linked to the root metaphors that underlie them and form the basis for evaluating the validity of analyses.
According to Pepper, there are four world hypotheses that can be considered “relatively adequate” because they explain the most phenomena with the fewest concepts. One of these is Contextualism. According to this worldview, on which ACT is based, no event can be understood in isolation from the context in which it occurs at that moment or from the historical context of the individual’s past experiences. The criterion that determines the correctness of an analysis concerning that event is its function. An analysis is considered “true” if it adequately takes into account the characteristics of the context in which the event occurs and leads to effective action, or if it makes it possible to successfully achieve a specific goal. In other words, the most important factor determining the meaning and truth of a thought or idea is not how much it reflects “reality,” but its function or how much it serves a specific purpose. An idea does not carry an immutable or absolute truth within itself. It is the lived events that make that idea true and meaningful.
According to RFT, human suffering arises from the interface between language and cognition and from direct experience. The phenomenon defined as “psychological inflexibility” stems from several sources: experiential avoidance of painful situations, cognitive entanglement / fusion, a conceptualized self, loss of contact with the present moment, and consequently, the inability to engage in behaviors guided by core values. Trying to change disturbing thoughts and emotions does not solve the problem; it rather exacerbates it. Therefore, the solution proposed is to use practices such as distancing oneself from thoughts and emotions (cognitive defusion) through the process of mindfulness, identifying one’s core values, and engaging in committed action to realize goals aligned with those values.
It is a matter of debate to what extent ACT is a different approach from CBT in terms of its theoretical basis, effectiveness, and mechanisms of action. Issues that have been debated for years and on which there is still no consensus include (i) the methodological quality of studies conducted with ACT and whether there is sufficient evidence for the treatment’s effectiveness (Öst, 2008; Gaudiano, 2009; Öst, 2009; Öst, 2014; Atkins et al., 2017), (ii) its effectiveness compared to CBT (Powers et al., 2009; Powers & Emmelkamp, 2009; Levin & Hayes, 2009), and (iii) whether it differs from CBT in terms of its mechanisms of action (Arch & Craske, 2008; Hayes, 2008). A more recent meta‑analysis (Gloster et al., 2020) showed that ACT is significantly effective compared to control conditions in various disorders such as anxiety, depression, and chronic pain. However, when compared with traditional CBT, most studies found no significant difference. The same meta‑analysis noted that the effect sizes of ACT are generally small to medium and that this effect is maintained during follow‑up periods.
While some authors (e.g., Hofmann & Asmundson, 2008) argue that ACT does not deserve the “third wave” therapy designation, ACT advocates (e.g., Gaudiano, 2011) argue the opposite. Furthermore, it has been noted that there are significant similarities between ACT and Morita therapy, which was developed in Far Eastern countries 80 years ago and is based on the philosophy of “accepting life as it is” (Hofmann, 2008; Leitan et al., 2015). This issue indeed casts a shadow over the claims that ACT is a new therapeutic approach.
In 2008, Bob Leahy, the then president of the Association for Behavioral and Cognitive Therapies, pointing to the commonalities between ACT and Morita Therapy in their underlying ideas and techniques, raised the question “Is this a coincidence?” He suggested that these ideas and techniques were directly taken (and without attribution) from Morita Therapy. Steve Hayes, the developer of ACT, denies this claim’ asserting that he had no knowledge of Morita Therapy until he developed and published ACT as a model. Even if Hayes is telling the truth, this does not mean that ACT is as new a treatment as claimed.
One can question the effectiveness and mechanisms of the mindfulness technique when it is used in other cultural contexts, stripped of its spiritual dimension. In the context of the mystical or spiritual life philosophy of Zen Buddhism, it might have some meaning or function. There are similarities between this philosophical thought and the concept of fatalism, especially “tawakkul” (surrender to God’s will), in Islamic cultures. It is conceivable that these phenomena might have some protective effect against stress through certain mechanisms. Furthermore, since this approach encourages not avoiding distressing thoughts and emotions, it can be considered to involve the technique of imaginal exposure. Thus, it might be effective to some degree. However, the effect of this behavioral technique alone is weak. It is not as effective as confronting anxiety- or fear-evoking situations in the natural environment (live exposure) (Hayes et al., 2006; Devilly & Foa, 2001; Keane et al., 1989). Indeed, a more recent meta‑analytic study (Frost et al., 2021) supports this difference. On the other hand, ACT might provide more therapeutic benefit by also recommending the cessation of avoidance behaviors in natural environments. It might therefore be as effective as CBT, but there does not yet seem to be convincing evidence that it is more effective than CBT.
On the website of the Association for Contextual Behavioral Science (ACBS), a list of criticisms made against ACT is provided, along with responses to these criticisms. Notable criticisms include: “the latest passing fad polluting the mental health field”; the view that “there is nothing new here”; “exaggerated claims not supported by data”; claims of a grand vision; the formation of a “cult” culture among its followers; efforts to gain adherents for the therapy as a “way of life”; and the use of “obscurantist jargon” that makes it difficult for everyone to understand the therapy and its theoretical basis. There may well be an element of truth in many of these criticisms. In response to the view that ACT does not bring any innovation, it is acknowledged that “many, if not all, techniques and strategies are borrowed.” However, it is claimed that the therapy being firmly tied to a theory and philosophy is an innovation. Since ACT advocates promote their therapy as a way life based on a certain philosophical outlook, it is worth examining the philosophical foundations of ACT more closely.
Critique of the Philosophical Foundations
The view that the truth of a thought or idea is determined not by how much it reflects “reality” but by its functionality is the view of Pragmatism. This view is also closely related to Empiricism. According to this view, an idea, analysis, or hypothesis is true if it leads to useful consequences. The only way to understand this is through inquiry, research, and scientific experiments. This philosophy was put forward in 19th‑century America by Charles Sanders Peirce and William James. Later, in the 20th century, it was developed by John Dewey, George Herbert Mead, and Jane Addams, who applied it to politics, social sciences, and education. It is claimed to be compatible with Darwin’s concept of “natural selection.” Just as traits that ensure the continuation of species are selected and preserved from generation to generation, ideas that lead to successful actions are similarly preserved. Because it contained the view that “it is true because it provides social benefits” in religious matters, it suited the puritan culture of America, especially in the 19th century. It was the dominant view in the country’s applications in social sciences, education, economy, and politics until the second half of the 20th century. Its popularity decreased during the Cold War period, but it was revived after the 1970s under the name of Neopragmatism.
ACT is built on functional contextualism, a derivative of this pragmatist philosophy. The philosophical basis of ACT measures the correctness of an analysis by “whether it works or not.” This pragmatic approach, while providing therapeutic flexibility, has been the target of five fundamental philosophical criticisms detailed below: (1) moral relativism, (2) a‑moral instrumentalism, (3) a‑ontological stance, (4) unclear and untestable constructs, and (5) cult culture and obscure jargon.
(1) Moral Relativism
American philosophers such as Leonard Harris (2002), John Diggins (1994), and Cornel West (1989) have brought important criticisms of Pragmatism. These authors argue that pragmatist philosophy does not contain moral values that would direct people to oppose injustices suffered by others and to defend the rights of oppressed people. This criticism is directly valid for functional contextualism, which is the basis of ACT. If a thought is true because it “works,” for whom does slavery or systemic injustice “work”? Harris’s analyses on this issue are particularly noteworthy. He points out that the “method of intelligence” advocated by Dewey – who is claimed to have made great contributions to the education system in the United States of America (USA) in the first half of the 20th century with his pragmatist approach – did not work at all during the era of slavery in the USA. The people who had the power to bring about social development were proponents of slavery. Societies that defend democratic freedoms are also typically societies where slavery exists. Pragmatist methods such as dialogue, inquiry, debate, and appealing to public opinion did not work for the abolition of slavery. Millions of people who opposed and protested slavery lost their lives. While this process continued, many people, including pregnant women, children, and the elderly, suffered consequences such as threats, beatings, lynching, and rape. Regarding contemporary America, Harris argues that while democratic participation is allowed, democracy operates through processes of exclusion and exploitation without central control. Corporations and wealthy families acquire enormous capital through these means, while the life and job options of many low‑income people are severely restricted.
Furthermore, the dominant pragmatist culture of the USA also manifests itself in the context of human rights and especially torture. As will be recalled, it was widely debated whether the “enhanced interrogation techniques” applied to people arrested on charges of “terrorism” during the Bush era constituted torture. Because of some of my publications on torture at that time, I had the opportunity to follow the process closely as I was a party to these debates. After a while, this debate turned into the question of whether torture is a useful interrogation method for obtaining accurate information from detainees, and it has continued to this day. While international law, in accordance with Kant’s philosophy, does not excuse torture under any circumstances, even human rights organizations in the USA at that time contributed to this debate from this pragmatist perspective (“torture does not work in interrogation”) rather than addressing the issue only from legal and moral aspects. This process has never ceased to amaze me in showing how deeply rooted this philosophical understanding is in the USA. It is possible to see many other examples of this in American foreign policy practices carried out in the name of “national interests” and leading to the disastrous consequences for millions of people around the world. Considering that the USA does not stand alone in the world in its pragmatist outlook, one can easily appreciate what a great risk the philosophical outlook poses for humanity, particularly in this nuclear age.
In the context of ACT, the problem of moral relativism is centered on the concept of “chosen values.” Hayes (2020), one of the founders of ACT, claims that arbitrariness is limited by “free choice,” saying, “Chosen values are not a means to an end; they are chosen because they are important to you.” The official statement of ACBS similarly states, “Functional contextualism uses chosen values as the necessary antecedent for the application of workability, as that which determines the criteria for evaluating workability” (ACBS, 2023). This means that one cannot decide if something “works” without first identifying the values one cares about. Those chosen values determine the criteria for what counts as “working.” This defense is inadequate. If a person chooses a value such as “harming others” or “racism,” what moral basis does ACT have to declare this choice “unworkable”? Zilio (2011) clearly expresses this dilemma, stating, “The pragmatic truth criterion of functional contextualism can be problematic because of relativism and the problem of grounding when used in the definition of values in ACT.”
(2) A‑moral Instrumentalism
Derived from moral relativism, this criticism argues that the instrumental nature of pragmatism turns every method (regardless of its moral content) into a means to an end. Öst (2014) stated that the philosophy underlying ACT “allows a‑moral instrumentalism and that this gives rise to various ethical problems.” As Harris (2002) points out, pragmatist methods (dialogue, negotiation, public opinion) – even if they technically “work” – are not sufficient to defend the rights of oppressed groups, because these methods do not question existing power relations. Harris asks: “Which principles, criteria, or directives of pragmatist philosophy force people to oppose the evils of the world, the trade in landmines, nuclear armament, the appropriation of great wealth in less developed countries and its transfer to rich Western countries, the sale of addictive drugs that destroy the lives of children and adults, the forced prostitution of people, and the sale of stolen babies and human organs, and to take action?”
In the context of ACT, this criticism is embodied in the concept of “acceptance,” one of the main goals of the therapy. ACT encourages “accepting life as it is.” Considering that a large part of the world’s population faces much more painful realities than Harris attempts to describe, the offering by ACT proponents of a pacifist philosophy such as “accept the world as it is” with a claim of a “grand vision” is nothing more than a bitter irony. What could ACT possibly say to those living below the poverty line in many countries, including the USA, to those whose children die of hunger in Africa, to those who have lost their loved ones and other possessions under American bombs in countries such as Iraq, Afghanistan, and more recently Iran, to those suffering the pain of torture, to those displaced by wars, to those who have suffered “natural” disasters caused by the disruption of the ecological balance – other than to accept everything as it is? This phenomenon clearly shows the poverty of thought and moral values of ACT and the traditional pragmatist philosophy on which it is based.
ACT proponents (e.g., Fletcher & Hayes, 2009) argue that instrumentalism is kept under control because “functional analysis is conducted within the therapeutic context.” However, this response is also inadequate. It is unclear by what means ACT can assess the harm caused outside the therapeutic context by the values chosen by the person in therapy (e.g., racism or violence). Furthermore, the meta‑analysis by Gloster and colleagues (2020) shows that ACT is not more effective than CBT. If ACT is only as effective as CBT, there is no reason to prefer a philosophically much more problematic approach.
(3) A‑ontological Stance
The functional contextualism on which ACT is based defines itself as an “a‑ontological” stance – it refrains from commenting on the nature of reality. While Fletcher and Hayes (2009) state that “ACT is based on functional contextualism, an a‑ontological philosophy,” Codd III (2015) explains, “Functional contextualists adopt an agnostic stance on ontology when applying pragmatic truth criteria.” This stance is considered problematic by critics for various reasons.
First, maintaining an a‑ontological stance in practice is impossible. Herbert and Padovani (2022) state, “If functional contextualism is to serve a guiding function for the science of psychology, it must assume the existence of reality.” Second, the a‑ontological stance itself carries an ontological claim. Even saying “I don’t comment on ontology” expresses a certain ontological position (agnosticism or anti‑realism). Third, Szabo and Tarbox (2022) note that this stance “may seem strange to outside practitioners and academics, and may create barriers to interdisciplinary collaboration.” Fourth, ACT’s own theoretical constructs – “psychological flexibility,” “relational frame theory” – contain ontological claims about the nature of mental processes. To say that these claims are “merely functional” amounts to merely avoiding questioning.
ACT proponents argue that the a‑ontological stance is a conscious methodological choice (Fletcher & Hayes, 2009) and that it is compatible with Bas C. van Fraassen’s “constructive empiricism” (Codd III, 2015). Szabo and Tarbox (2022) suggest that “ontological language” can be used when necessary – but as a pragmatic tool, without making an ontological claim.
However, these defenses are inadequate. Even the criterion of “empirical adequacy” requires an implicit ontology. The concept of “observable phenomena” presupposes a distinction between observer and observed – which itself is an ontological claim. The suggestion to use ontological language as a “pragmatic tool” contradicts the essence of the a‑ontological stance. To use a term (e.g., “reality”) meaningfully, at least a minimal ontological claim about the referent of that term is necessary. As Herbert and Padovani (2022) point out, “When functional contextualism avoids making the ontological assumptions necessary for guiding scientific activity, it becomes inconsistent with its own practical goals.” Even on the ACBS website, there are different and contradictory views on whether the a‑ontological stance is defensible (Monestes & Villatte, 2013; Herbert & Padovani, 2022). This situation shows that the a‑ontological stance is not a clear and consistent philosophical position.
(4) Unclear and Untestable Constructs
ACT’s most central concept, psychological flexibility, is defined as the ability to fully experience the present moment and to change or persist in one’s behavior in the service of chosen values. However, the clarity of this definition is debatable. Cherry and colleagues (2021) demonstrated that, despite the popularity of the concept of psychological flexibility, similar concepts have existed since the mid‑20th century, and that different terms, definitions, and measurement tools have hindered progress in the field. The defining features that distinguish ACT’s concept from others (such as cognitive flexibility, emotion regulation, psychological resilience) are not sufficiently clear.
The most concrete reflection of this ambiguity is the validity problems of the main tool developed to measure psychological flexibility, the Acceptance and Action Questionnaire (AAQ‑II). Tyndall and colleagues (2019) have shown that the AAQ‑II items actually measure “general psychological distress” directly and share almost the same variance with general psychopathology, independent of psychological inflexibility. Wolgast (2014) also revealed that the factor structure of the AAQ‑II is inconsistent and that the reverse coding of some items creates artificial factors. These criticisms provide strong evidence that what the AAQ‑II measures is not “psychological flexibility” but rather “general psychological distress.”
ACT advocates have responded to these criticisms. Ruiz and colleagues (2024) recommend using the AAQ‑II only as a measure of psychological inflexibility and acknowledge that the scale needs revision. However, this defense does little more than argue against the conclusion that the concept itself is invalid. Moreover, the link between the Relational Frame Theory (RFT) underlying ACT and clinical change is equally unclear. Although Hayes et al. (2012) claim a theoretical coherence between RFT and ACT, almost all ACT research uses scales like the AAQ‑II rather than directly testing the predictions of RFT. This creates a serious gap between theory and practice (Levin et al., 2017; Stockton et al., 2019).
From the perspective of philosophy of science, when a concept such as “psychological flexibility” is not fully defined, whether it “works” cannot be meaningfully tested. This circularity is a serious problem in terms of Popper’s criterion of falsifiability. If every observation can be interpreted as evidence of psychological flexibility, then no observation can falsify it. Indeed, Gloster and colleagues (2020) showed that ACT is not more effective than CBT, revealing the practical consequences of conceptual ambiguity. This situation renders the scientific status of ACT’s basic constructs questionable.
(5) Cult culture and obscure jargon
The criticisms that ACT is a cult are interesting. On the ACBS website, in response to this criticism, it is pointed out that the definition of a “cult” includes elements such as a closed system, a charismatic leader, a strong financial gain motive, economic and/or sexual exploitation of vulnerable people, secret stages to be passed through to gain exclusive knowledge or status, intolerance of dissent, challenging the status quo, containing a grand vision, and creating strong excitement among followers. It is then argued that ACT possesses only the last three of these features and that these features alone cannot distinguish science from a cult. The website advises its followers, “This is a silly claim; ignore it” (Herbert, 2005, ACBS website). Herbert (2005) argues that a “cult” is defined by “closed system,” “charismatic leader,” “secret stages,” and “intolerance of dissent,” while ACT and ACBS are, on the contrary, “open to everyone’s participation, criticism, and different views.”
I do not know the ACT circles, so I cannot make a definite judgment on this matter. However, even if a community around an idea and its leader that offers an exciting “philosophy of life” or “grand vision” does not constitute a cult in the strict sense, the possibility that the social environment exhibits some “cult‑like” characteristics needs to be taken seriously. Such characteristics could raise questions about the scientific validity of work conducted in that environment. After all, an idea generating strong excitement stems from a strong belief in that idea, and strong beliefs are not a mental process compatible with scientific skepticism. Furthermore, the spiritual nature of the offered philosophy of life nourishes strong belief and excitement. The fact that groups of people gathered around different ideas and the ideals they nourish often lead to an “us” and “them” distinction, competition between these groups, and the advantages (which do not always have to be material) that one idea winning over another might provide to its followers are factors that can negatively affect the scientific quality of the work. Although this is true for all psychotherapies (including CBT), when the therapy’s philosophy of life, opposition to the status quo, or other “grand visions” are brought to the forefront, this problem is expected to emerge more seriously. I do not think the criticism leveled against ACT is based on a literal understanding of a cult. Such an assumption would be absurd and would imply underestimation of the intelligence of those making the criticism. Nevertheless, I find it meaningful that the ACBS website so easily dismisses the criticism by simply overlooking the intended meaning of a cult.
The above criticism is only part of a larger group of criticisms. Other criticisms directed at ACT in the literature include “overly‑hyped claims,” “getting ahead of the data,” “excessive enthusiasm,” “excessive and grandiose visions,” proselytizing, “a way of life” as ACT, “coercive and manipulative experiential exercises,” “early proliferation through self‑help books,” “obscurantist jargon,” and “nothing new” claims (Herbert, 2005). Many of these criticisms arise from the perception that ACT offers more than just a therapy – a “philosophy of life” or “grand vision.” These criticisms appear to have led to a defensive attitude among followers of ACT and a tendency to accuse critics of “not understanding enough.” For example, in his classification of these criticisms, Herbert (2005) noted that “these criticisms are based on ignorance, stylistic differences, or challenging the status quo” risks, thereby reducing valid philosophical or scientific concerns to the category of “ignorance.”
The real issue here is not whether the “cult” label is accurate, but how the group dynamics pointed out by these criticisms can affect scientific quality. In the literature, the “us and them” perception of a group, “dogmatic defensiveness” (Gaudiano, 2009), and the tendency to dismiss criticism as “ignorance” have been identified as serious obstacles to scientific progress (Öst, 2014). ACT’s philosophical claims are also directly linked to the criticism of “obscurantist jargon.” Öst (2008) argues that terms used by ACT (such as “cognitive defusion”) are merely relabeling of existing behavioral or cognitive concepts. He further argues that such specialized and difficult‑to‑understand jargon can make communication with different schools difficult, rendering the ACT community almost completely closed to external criticism and participation.
Herbert (2005) defends this situation by saying, “One person’s obscure jargon is another’s technical vocabulary.” While this is true, the requirement that ACT’s philosophical foundations be understood (“ACT cannot be properly applied without understanding functional contextualism and RFT”; Hayes, 2004) can create an “esotericism” that contradicts pragmatist claims. If therapy is merely a technology that “works,” why do users need to grasp a complex philosophy and basic science first? This contradiction is one of the most fundamental tensions in ACT’s relationship with pragmatism. It makes the following question at the heart of the “cult” criticism, inevitable: Is ACT a science, or a worldview that risks turning into a belief system?
Dialectical Behavior Therapy (DBT)
DBT is a therapeutic approach developed by Marsha Linehan in the 1980s, primarily for “Borderline Personality Disorder.” Later, it was also used for the treatment of conditions such as depression, bulimia, bipolar disorder, substance abuse, and Post‑Traumatic Stress Disorder. The aim of the therapy is defined as the reduction of problematic behaviors caused by dysregulated emotions. An example of such problematic behaviors is avoiding stimuli that generate emotions (Lynch et al., 2006). It is understood that DBT has many features in common with ACT. These include the practice of mindfulness and many techniques of classical cognitive and behavioral therapy. Also, as in ACT, the goal of the therapy is not to change thoughts, but to change perceptions of thoughts and reduce the impact of thoughts on behavior (Linehan, 1993). Unlike ACT, the practice of mindfulness in DBT is not about distancing oneself from one’s thoughts, but about “entering into” thoughts, “joining” them, and “being one” with them.
The feature that distinguishes DBT from other therapies is that it is based on dialectical philosophy and therefore involves “dialectical” strategies. According to this philosophy, which includes Hegel’s famous thesis, antithesis, synthesis view, there is an absolute Truth in the universe, but there are also multiple truths that change depending on the context and are in a state of constant change. It is stated that DBT contains the synthesis of these two views. Examples given of the dialectical approach include: the therapy not aiming to change problematic thoughts on one hand while aiming for change towards solving the problem on the other; the therapist sometimes making statements or taking attitudes that are completely opposite (polar opposite) to previously asserted views; the therapist completely reversing their position in a potential argument that might arise due to statements contrary to the patient’s beliefs, thus providing an example for the patient on how to be flexible in thinking; and sometimes playing “devil’s advocate.” It is thought that these practices facilitate learning processes by focusing the patient’s attention on the topic and bring flexibility to rigid patterns of thought, emotion, and behavior.
It can be said that DBT is fundamentally a form of CBT (Linehan & Wilks, 2015; Linehan et al., 2015). Indeed, many sources state that DBT is a direct derivative of CBT and was developed because traditional CBT proved insufficient for women with chronic suicidal behavior and borderline personality disorder (Chapman, 2024). The point where DBT diverges from CBT is that the therapy is guided by three fundamental theoretical foundations: behavioral science, acceptance, and dialectical philosophy (Chapman, 2024). The simultaneous use of these three elements is the fundamental difference claimed to distinguish DBT from classical CBT.
The most obvious structural innovation of DBT is that the therapy is not limited to individual therapy sessions. It simultaneously includes multiple components such as skills training groups, telephone coaching, and a therapist consultation team (Chapman, 2024). In this respect, unlike traditional psychotherapies conducted by a single therapist, DBT is a “treatment program.” The four core skill modules are mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance (Linehan, 1993). These modules allow the therapy to combine both acceptance‑focused and change‑focused strategies. In particular, the mindfulness and distress tolerance modules are acceptance‑oriented, while the emotion regulation and interpersonal effectiveness modules are change‑oriented. This structured and multi‑component format distinguishes DBT from other CBT derivatives.
Another distinctive feature of DBT is that it has its own original model explaining the development of borderline personality disorder, called the biosocial theory (Linehan, 1993). According to this theory, emotion dysregulation results from the interaction of a biological predisposition with an invalidating environment. Since DBT’s treatment strategies are derived from this theory, DBT – unlike CBT – is one of the first third‑wave therapies based on a specific psychopathology model. This feature aims to make DBT a theoretically consistent treatment system rather than just a collection of techniques.
The dialectical strategies used to manage the tension between acceptance and change are the most emphasized element of DBT’s claim to be innovative. These strategies aim to help the patient hold two opposing views together, avoiding rigid polarizations (Linehan, 1993). However, to what extent these strategies are truly new and whether they possess features not found in other treatments will be reviewed in more detail below.
Dialectical Philosophy and DBT
It is claimed that the first of the examples given above is the approach that best characterizes the dialectical nature of the therapy. Although the content of problematic thoughts is not intended to be changed in therapy, the very approach of mindfulness itself, by its definition, involves a change: instead of avoiding disturbing thoughts, not avoiding them; instead of judging them, not judging them. So, here, one method is being used instead of another to effect change. However, there is no quality of being polar opposites between these two methods. For example, in Hegel’s classic example, “being” and “nothing” are polar opposites. They negate or cancel each other out, but simultaneously contain each other and together constitute a higher concept, “becoming.” That is not the case here. Furthermore, what determines dialectical nature is not necessarily that two concepts are polar opposites, but that they are different from each other and positioned “against” each other. [It is understood that the confusion of meaning created by Hegel’s philosophy stems from the difficulties in translating the German word “entgegensetzen” into English. The Stanford Encyclopedia of Philosophy translates this word into English as “to set over against,” which does not imply a polar opposition. The meaning of this phrase can be thought of as “to be placed or positioned against.”]
It is debatable what the dialectical terms used in DBT (e.g., “acceptance‑change tension”) mean outside the therapeutic context or to what extent these concepts are compatible with Hegelian dialectics. In DBT, dialectic functions more as an art of balancing two opposing views. In Hegel, it is a process of progression, a process of sublation (Aufhebung). This is a key concept in Hegelian philosophy describing the process by which two opposing ideas (thesis and antithesis) are not simply discarded or one defeated, but are simultaneously cancelled, preserved, and lifted up into a higher, more comprehensive unity (synthesis). DBT uses a “superficial dialectic” lacking this philosophical depth. This situation gives the impression that DBT’s ambitious philosophical terminology serves to make the therapy mysterious and attractive rather than explaining its real mechanisms.
When dialectic is understood in Hegel’s sense, it can be said that every scientific approach has a dialectical nature. It is a well‑known fact that in the process of scientific methodology, starting from the opposition of different views and theories, a conclusion (synthesis) is reached through a testing process. Furthermore, since dialectical philosophy asserts that everything in the universe is subject to dialectical laws, this phenomenon is also valid for all types of psychotherapy methods. Therefore, claiming that a therapy has “dialectical” features (unless it means that it is slightly more dialectical than other therapies!) is totally meaningless. DBT’s attempt to adapt this philosophy to therapy can be seen as a marketing strategy rather than philosophical depth. Indeed, there are criticisms in the literature that “while dialectical processes are already inherent in every psychotherapy, making it a brand is an exaggerated claim” (Hofmann & Asmundson, 2008). A therapist presenting different perspectives or testing the patient’s beliefs during a session are common techniques performed without being labeled dialectical.
Effectiveness of the Therapy and Methodological Problems
There are many randomized controlled trials (RCTs) and meta‑analyses showing that DBT is effective in the treatment of borderline personality disorder (DeCou et al., 2019; Miga et al., 2019). However, a significant portion of these studies compare DBT with other therapies specifically designed for borderline personality disorder, such as mentalization‑based therapy, transference‑focused therapy, and schema therapy. They do not test which component of the therapy is effective (component analysis) or what contribution the dialectical philosophy of DBT alone makes.
An interpretive evaluation by Ujhelyi‑Gomez and colleagues (2025) on a meta‑analysis of 11 RCTs concluded that although there is some evidence that DBT may reduce self‑harm behaviors and depression in individuals with borderline personality disorder, this evidence should be treated with caution. This is because of methodological limitations and the high risk of bias detected in the RCTs (Ujhelyi‑Gomez et al., 2025). Scheel (2000) also noted that there are serious methodological difficulties in the empirical literature supporting DBT. These difficulties prevent DBT from being accepted as a “fully established clinical approach.” These criticisms raise the concern that the speed of DBT’s popularization may have outstripped the rigor of its scientific evidence base.
A particularly noteworthy point is that the use of DBT for disorders other than borderline personality disorder (depression, bipolar disorder, substance abuse, post‑traumatic stress disorder) is based on studies with adapted versions of the therapy for these populations (Chapman, 2024). The number of these studies is quite small compared to borderline personality disorder studies. Most are small‑sample or pilot studies. More research is needed to reach definitive conclusions about the effectiveness of DBT in other disorders. Moreover, the fact that standard DBT covers a long period such as one year is a factor that complicates the cost and applicability of the therapy.
Mechanisms of Action
As in the criticism of ACT, the problem of “unclear and untestable constructs” is also valid for DBT. What “dialectical thinking” – one of DBT’s basic concepts – means, how to measure it, and what contribution it makes to treatment outcomes are not sufficiently clear. The number of studies testing DBT’s mechanisms of action in the literature is quite limited. Existing studies generally examine the mediating role of DBT’s skill training modules (emotion regulation, distress tolerance, etc.). However, the relationship between the acquisition of these skills and the “dialectical” process is not clear. It is difficult to say with certainty which skill works through which mechanism. DBT’s multi‑component structure makes it difficult to distinguish which component (individual therapy, skills group, telephone coaching) is responsible for change.
In this context, criticisms that the innovations DBT presents as a “third‑wave” therapy (especially acceptance and mindfulness techniques) can also be found in other treatments – and that the effect sizes of these techniques may have been exaggerated – are noteworthy. Indeed, studies comparing DBT with other third‑wave therapies such as schema therapy, mentalization‑based therapy, or ACT (Stoffers‑Winterling et al., 2022) do not provide consistent evidence that DBT is significantly superior. This suggests that DBT’s dialectical philosophy or specific techniques do not provide an additional advantage over other well‑structured treatments. The acceptance of DBT as the “gold standard” in the treatment of borderline personality disorder may be more due to the number of studies conducted in this area and the structured, interventionist nature of the therapy. However, this does not mean that it is inherently more effective than other treatments.
DISCUSSION AND CONCLUSIONS
The high prevalence of stress and related problems in Western societies has led to the emergence and institutionalization of many psychotherapies. Factors contributing to stress include problems arising from the competitive economic system, alienation from work, pressures of consumer culture, excessive individualization, loss of control over life, lack of social and emotional support, loneliness, and existential difficulties such as the inability to find meaning in life. Psychotherapies starting with Freud have not been able to solve these problems; at best, they have helped keep them under some control. Behind the increasing interest of Western societies in the mystical life philosophies of the Far East over the last 50 years lies a search for a solution to these problems. If the efforts to integrate spiritual philosophies into cognitive‑behavioral therapies are not merely attempts to turn this interest into personal opportunity, they may stem from the desperation caused by the failure to overcome the limitations of existing approaches.
Considering the evidence reviewed in this article, neither CBT nor its “third‑wave” derivatives have advanced the traditional behavioral approaches that have been developing since the early 20th century. On the contrary, they could well be seen as a step backwards. They have shifted attention from behavior to cognition, making it harder to understand what actually works in psychotherapy. Moreover, they have confused the issue by relying on a superficial understanding of Eastern spiritual philosophies. With increasingly complex concepts – and therefore increasingly complex methods – it has become even more difficult to understand what causes what in treatment. It is unrealistic to expect any single approach, including the behavioral approach, to solve every human problem. Nevertheless, “grand visions” have been put forward, claiming to be “holistic” and to encompass the entirety of human existence. Most concerning of all is the pragmatist foundation of these approaches, which is essentially a minefield in terms of its moral implications. These approaches will most likely fade into history after completing their course.
Examining CBT and its derivative therapies in light of what we know about Control‑Focused Behavioral Treatment (CFBT) – an intervention we have been developing since the early 1990s (Başoğlu et al., 2011) – might be helpful in understanding their shortcomings. CFBT is designed to enhance the sense of control over, and resilience against, stressful events. It differs radically from other therapies in primarily aiming for increase in sense of control over stressors, rather than reduction in anxiety directly. It focuses solely on avoidance behaviors, with no systematic cognitive intervention or any other anxiety‑reducing techniques. Furthermore, unlike other therapies, CFBT can involve exposure to both conditioned and unconditioned stimuli (including simulated versions of original traumatic events). It has been tested in five studies (two randomized controlled) with survivors of earthquakes, war, and torture. A meta‑analytic comparison (Başoğlu, 2022, Figure 3) shows that CFBT achieves improvement rates of 80‑90% when delivered in 1‑2 sessions, compared to improvement rates of 40‑50% for other evidence‑based treatments (including CBT and its derivatives).
How can this finding be explained, and what does it mean for other psychotherapies? The answer to these questions should be quite clear. Since treatment involves only self-exposure to anxiety cues, the process that brings about recovery is clearly the reduction in avoidance behaviors and the consequent increase in the sense of control. The remarkably high recovery rates support the view that an increased sense of control plays a central role in recovery.
CFBT can be described as a naturalistic approach. We know that after mass disasters such as earthquakes, many people recover by using self‑exposure in their natural environment, without any external guidance (Başoğlu et al., 2011). This may well reflect an evolutionary tendency in humans to use this form of coping. Indeed, ethology and evolutionary psychology show that animals and humans abandon avoidance behaviors when those behaviors begin to impair vital functions, even at the risk of continuing threats to life (Kavaliers & Choleris, 2001; Lima, 1998). Such evidence implies that the ability to sustain life by taking risks in fear‑evoking situations has evolved over time. CFBT was modeled on this natural recovery process, which may explain its remarkable efficacy. When the innate natural recovery potential is blocked by helplessness or hopelessness cognitions, CFBT can be seen as simply removing the blockage and facilitating natural recovery.
This naturalistic understanding of resilience is supported by many examples of resilience‑building outside any therapeutic context. In our studies with torture survivors (Başoğlu et al., 1994a, 1994b, 1997) we defined resilience as “the capacity to exert sufficient control over stressful events by employing cognitive and/or behavioral strategies to either prevent the stressor, or, if unavoidable, take reasonable steps to protect oneself from its harmful effects, use strategies to reduce associated distress, or simply endure or tolerate it without losing control.” Using a Psychological Preparedness for Torture Scale, we found that political activists – who were psychologically prepared for arrest and torture through their political commitment, prior knowledge, and training in physical and mental stoicism – showed remarkably low rates of PTSD (18%) and major depression (2%) despite having experienced an average of 291 exposures to 23 forms of torture. In contrast, non‑activist survivors, who experienced much less severe torture, had substantially higher rates of PTSD (58%) and depression (24%). Psychological preparedness emerged as the strongest predictor of PTSD, underscoring the critical role of perceived control and resilience in mitigating the long‑term impact of extreme adversity. Such resilience can be explained by prior experiences that enable individuals to exercise effective control strategies – removing or warding off threat, reducing the impact of unavoidable events, and gaining control over fear. Effective control reduces anxiety during exposure, facilitates recovery, and reinforces expectations of future control. Indeed, achieving control over stressors is known to have protective or immunizing effects against future uncontrollable stressors (Hannum et al., 1976; Seligman & Maier, 1967; Williams & Maier, 1977). It is worth noting here that evidence from a treatment study of panic disorder and agoraphobia that compared the effectiveness of alprazolam with exposure treatment has shown that (a) improvement can occur even without a reduction in anxiety or panics during treatment (Başoğlu et al, 1994a), and (b) attributions of improvement to an external agent (e.g. anxiolytics) undermines sense of control over anxiety and leads to relapse after treatment (Başoğlu et al., 1994b). Both findings point to the critical role of increased sense of control in recovery.
Resilience‑building through exposure to anxiety or distress is not a novel concept. It can be observed in various Eastern philosophical and religious traditions. For example, Buddhist training involves exposure to austere conditions and actively promotes mental control and tolerance of suffering. Such resilience training is thought to explain the low rates of traumatic stress observed in Tibetan monks who have been subjected to torture (Holtz, 1998). Similarly, in the Mevlevi order of Islamic Sufism, new members (dervishes) undergo a 40‑day period of solitary confinement in a small, enclosed space, living with little food and sleep, and praying. This practice, called “çile doldurmak” in Mevlevi terminology, is an experience of continuous and prolonged suffering. If someone loses control and terminates the period prematurely, they are expected to start again. The idea is to achieve “spiritual maturation” by building mental and emotional control over anxiety or suffering caused by deprivation of basic human needs. From a psychological perspective, this training technique clearly utilizes the same basic principles as CFBT.
Similar resilience‑building strategies are also used in the training of soldiers, commandos, special forces, and political activists. The SERE (Survival, Evasion, Resistance, and Escape) program, used in the training of some military personnel in the United States, involves controlled exposure to “torture‑like” procedures to increase resilience against brutal interrogation techniques or torture. The core principle is the same: by gradually exposing individuals to stressors in a controlled setting, they learn to manage and tolerate distress effectively.
These examples provide valuable insights into how humans cope with extreme stress, what resilience truly means, and how it can be developed. It was indeed such insights that inspired us to shift the focus of behavioral treatment from habituation to strengthening the sense of control. With this background knowledge, it becomes easier to recognize how radically different CFBT is from other psychotherapies that prioritize anxiety reduction. Those other approaches stem from entirely different philosophical foundations and socio‑cultural contexts. It is no accident that methods specifically aimed at fostering resilience originate from cultures where poverty, hardship, and suffering have historically been prevalent – in contrast to the affluence and relatively sheltered social environments of Western societies.
One can also recognize echoes of these principles in Stoic philosophy. The Stoics, particularly Epictetus and Marcus Aurelius, taught that while we cannot control external events, we can control our responses to them. They advocated for deliberately confronting discomfort to develop inner strength – a practice known as premeditatio malorum (the pre‑meditation of evils). This involves imagining and voluntarily facing hardship to reduce its power over the person. Such a practice bears a clear resemblance to the exposure‑based resilience building of CFBT. However, CFBT does not derive from Stoicism. The fact that its principles are consistent with certain ancient wisdom traditions only speaks to the universality of the underlying learning processes. CFBT’s power lies in its grounding in modern learning theory and evolutionary biology, not in any appeal to authority or tradition.
Unlike the third‑wave therapies, which derive their philosophical rationale from pragmatism and Eastern‑inspired mindfulness, CFBT does not rest on any philosophical or spiritual tradition. Its foundation is entirely empirical. The core principle – that facing feared stimuli increases a sense of control and builds resilience – is derived from experimental and clinical observations, not from a priori beliefs about the nature of truth or the good life. CFBT’s goal of enhancing resilience is not a “chosen value” in the pragmatist sense; it is a scientifically established target. The evidence shows that increased sense of control leads to recovery, regardless of whether the individual values that outcome or not. This is a factual claim, not a moral or philosophical one.
Our research shows that the most effective method – at least for treating conditions such as anxiety disorders and PTSD – is self‑exposure to anxiety cues in the natural environment, with the explicit purpose of enhancing resilience. The efficacy of self‑exposure in the context of CFBT also implies that there is no need for cognitive interventions or for approaches based on abstract and obscure philosophical concepts. It can be argued that all psychotherapies, regardless of the techniques they use, provide recovery only to the extent that they increase the sense of control over stressors, whether directly or indirectly. Given the existing evidence showing that cognitive interventions do not add any benefit when used together with exposure treatment, it is difficult to understand the rationale behind the insistence on such interventions.
Setting aside the underlying philosophies of third‑wave therapies such as ACT and DBT, do they truly represent an innovation in the field of psychotherapy? Considering the literature reviewed in this article, an affirmative answer is difficult to sustain. Having been aware of the importance of focusing on avoidance behaviors since the 1980s, I must say that the shift in focus from cognitions to avoidance behaviors in ACT and DBT – even if for different theoretical or philosophical reasons – is a noteworthy development from a behavioral perspective. However, this does not constitute an innovation. Behavior therapists have long recognized two important insights: (1) anxiety or fear arising from classical conditioning processes is beyond cognitive control, and (2) cognitions change with behavioral change. Thus, by shifting the focus of treatment from cognition to behavior – by not attempting to change cognitions and by encouraging non‑avoidance – these therapies have actually taken a step backwards in a different sense (chronologically) toward a more behavioral approach. In a way, this can be seen as reversing the shift from behavior to cognition that occurred during the so‑called cognitive revolution of the 1990s. However insufficient, I see this as a positive development, but certainly not as an innovation, especially considering that CFBT has existed for nearly 30 years.
The fact that there is no evidence showing these therapies to be more effective than classical CBT is an issue that needs careful consideration, and its reasons should be investigated. If indeed they are not more effective, this means that mere “acceptance” of anxiety‑evoking cognitions – essentially a cognitive process – does not, by itself, make a significant difference in treatment outcome. Any noteworthy therapeutic benefit that may arise is likely to come from the non‑avoidance (exposure) component of these therapies, but this needs to be confirmed by further research. Our work with CFBT suggests that two elements are critically important in achieving behavioral change: (a) a sharp focus on avoidance behaviors, and (b) a naturalistic treatment rationale that people find highly intuitive, easy to understand, and empowering. The absence of these elements in “third wave” therapies may well explain why they do not yield better outcomes than CBT.
References
ACBS. (2023). What is functional contextualism? Association for Contextual Behavioral Science. https://contextualscience.org/functional_contextualism
Arch, J. J., & Craske, M. G. (2008). Acceptance and commitment therapy and cognitive behavioral therapy for anxiety disorders: Different treatments, similar mechanisms? Clinical Psychology: Science & Practice, 15(3), 263-279.
Atkins, P. W. B., Ciarrochi, J., Gaudiano, B. A., Bricker, J. B., Donald, J., et al. (2017). Departing from the essential features of a high quality systematic review of psychotherapy: A response to Öst (2014) and recommendations for improvement. Behaviour Research and Therapy, 97, 259-272.
Baardseth, T. P., Goldberg, S. B., Pace, B. T., & Minami, T. (2018). A meta‑analysis of cognitive‑behavioural therapy for anxiety disorders: Relative efficacy and comparisons with other therapies. Clinical Psychology Review, 60, 1–12.
Başoğlu, M. (1984). The symptomatology of depressive illness in Turkey – A factor‑analytic study of 100 depressed outpatients. Journal of Affective Disorders, 6(3), 317-330.
Başoğlu, M. (2022). Control‑Focused Behavioral Treatment: A brief intervention for survivors of war and torture. Torture, 32(1-2), 251-263.
Başoğlu, M., Livanou, M., & Şalcıoğlu, E. (2003b). A single session with an earthquake simulator for traumatic stress in earthquake survivors. American Journal of Psychiatry, 160(4), 788-790.
Başoğlu, M., Livanou, M., & Şalcıoğlu, E. (2007). A randomized controlled study of single‑session behavioural treatment of earthquake‑related post‑traumatic stress disorder using an earthquake simulator. Psychological Medicine, 37(2), 203-213.
Başoğlu, M., Livanou, M., Crnobarić, C., Frančišković, T., Suljić, E., Đurić, D., & Vranešić, M. (2005). Psychiatric and cognitive effects of war in former Yugoslavia – Association of lack of redress for trauma and posttraumatic stress reactions. Journal of the American Medical Association, 294(5), 580-590.
Başoğlu, M., Livanou, M., Şalcıoğlu, E., & Kalender, D. (2003a). A brief behavioural treatment of chronic post‑traumatic stress disorder in earthquake survivors: Results from an open clinical trial. Psychological Medicine, 33(4), 647-654.
Başoğlu, M., Marks, I. M., Kılıç, C., Brewin, C. R., & Swinson, R. P. (1994b). Alprazolam and exposure for panic disorder with agoraphobia: Attribution of improvement to medication predicts subsequent relapse. British Journal of Psychiatry, 164(5), 652–659.
Başoğlu, M., Marks, I. M., Kılıç, C., Noshirvani, H., & O’Sullivan, G. (1994a). The relationship between panic, anticipatory anxiety, agoraphobia, and global improvement in panic disorder with agoraphobia treated with alprazolam and exposure. British Journal of Psychiatry, 164(5), 647–652.
Başoğlu, M., Mineka, S., Paker, M., Aker, T., Livanou, M., & Gök, S. (1997). Psychological preparedness for trauma as a protective factor in survivors of torture. Psychological Medicine, 27(6), 1421-1433.
Başoğlu, M., & Paker, M. (1995). Severity of trauma as predictor of long‑term psychological status in survivors of torture. Journal of Anxiety Disorders, 9(4), 339-350.
Başoğlu, M., Paker, M., Özmen, E., Taşdemir, O., & Şahin, D. (1994b). Factors related to long‑term traumatic stress responses in survivors of torture in Turkey. Journal of the American Medical Association, 272(5), 357-363.
Başoğlu, M., Paker, M., Özmen, E., Taşdemir, O., Şahin, D., Ceyhanlı, A., & İncesu, C. (1996). Appraisal of self, social environment, and state authority as a possible mediator of posttraumatic stress disorder in tortured political activists. Journal of Abnormal Psychology, 105(2), 232-236.
Başoğlu, M., Paker, M., Paker, O., Özmen, E., Marks, I., İncesu, C., et al. (1994a). Psychological effects of torture: A comparison of tortured with nontortured political activists in Turkey. American Journal of Psychiatry, 151(1), 76-81.
Başoğlu, M., & Şalcıoğlu, E. (2011). A mental healthcare model for mass trauma survivors: Control‑Focused Behavioral Treatment of earthquake, war, and torture trauma. Cambridge University Press.
Başoğlu, M., Şalcıoğlu, E., Livanou, M., Kalender, D., & Acar, G. (2005). Single‑session behavioral treatment of earthquake‑related posttraumatic stress disorder: A randomized waiting list controlled trial. Journal of Traumatic Stress, 18(1), 1-11.
Beck, A. T., Emery, G., & Greenberg, R. L. (1985). Anxiety disorders and phobias: A cognitive perspective. Basic Books.
Benish, S. G., Imel, Z. E., & Wampold, B. E. (2008). The relative efficacy of bona fide psychotherapies for treating post‑traumatic stress disorder: A meta‑analysis of direct comparisons. Clinical Psychology Review, 28, 746–758.
Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). A multidimensional meta‑analysis of psychotherapy for PTSD. American Journal of Psychiatry, 162, 214-227.
Burns, D. D., & Spangler, D. L. (2001). Do changes in dysfunctional attitudes mediate changes in depression and anxiety in cognitive behavioral therapy? Behavior Therapy, 32, 337–369.
Chapman, A. (2024). The state of the science: Dialectical behavior therapy. Behavior Therapy, 55(6), 1233-1248.
Cherry, K. M., Hoeven, E. V., Patterson, T. S., & Lumley, M. N. (2021). Defining and measuring “psychological flexibility”: A narrative scoping review of diverse flexibility and rigidity constructs and perspectives. Clinical Psychology Review, 84, 101973.
Clark, D. M., Ehlers, A., Hackmann, A., McManus, F., Fennell, M., Grey, N., et al. (2006). Cognitive therapy versus exposure and applied relaxation in social phobia: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 74(3), 568–578.
Clark, D. M., Salkovskis, P. M., Hackman, A., Middleton, H., Durbin, D., Wells, A., & Gelder, M. (1994). Authors’ reply. British Journal of Psychiatry, 165, 556-557.
Clark, D. M., Salkovskis, P. M., Hackman, A., Middleton, H., Wells, A., & Gelder, M. (1995). Authors’ reply. British Journal of Psychiatry, 165(4), 541-542.
Clark, D. M., Salkovskis, P. M., Hackmann, A., Middleton, H., Anastasiades, P., & Gelder, M. (1994). A comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder. British Journal of Psychiatry, 164, 759–769.
Cloitre, M. (2009). Effective psychotherapies for posttraumatic stress disorder: A review and critique. CNS Spectrums, 14(1 Suppl 1).
Codd III, R. T. (2015). The functional contextual a‑ontological stance and Bas C. van Fraassen’s constructive empiricism. Journal of Contextual Behavioral Science, 4(4), 225–232.
Cuijpers, P., Karyotaki, E., de Wit, L., & Ebert, D. D. (2020). A meta‑analysis of cognitive‑behavioural therapy for adult depression, alone and in comparison with other treatments. Canadian Journal of Psychiatry, 65(1), 5–17.
Cuijpers, P., Karyotaki, E., Reijnders, M., & Ebert, D. D. (2019). Are psychotherapies equally effective for depression? Journal of Clinical Psychology, 75(6), 1023–1039.
Cuijpers, P., Quero, S., Noma, H., Ciharova, M., Miguel, C., Karyotaki, E., & Cipriani, A. (2021). Cognitive behaviour therapy vs. other psychotherapies for depression: A meta‑analysis. JAMA Psychiatry, 78(9), 981–990.
Dattilio, F. M., & Norcross, J. C. (2006). Psychotherapy integration and the emergence of instinctual territoriality. Archives of Psychiatry and Psychotherapy, 8(1), 5–16.
DeCou, C. R., Comtois, K. A., & Landes, S. J. (2019). Dialectical behavior therapy is effective for the treatment of suicidal behavior: A meta‑analysis. Behavior Therapy, 50(1), 60-72.
Devilly, G. J., & Foa, E. B. (2001). The investigation of exposure and cognitive therapy: Comment on Tarrier et al. (1999). Journal of Consulting and Clinical Psychology, 69, 114-116.
Diggins, J. P. (1994). The promise of pragmatism. University of Chicago Press.
Ehlers, A., Clark, D. M., Hackmann, A., McManus, F., Fennell, M., Herbert, C., & Mayou, R. (2003). A randomized controlled trial of cognitive therapy, a self‑help booklet, and repeated assessments as early interventions for posttraumatic stress disorder. Archives of General Psychiatry, 60, 1024-1032.
Fletcher, L. B., & Hayes, S. C. (2009). Phenomenology and modern behavioral psychology. Philosophy, Psychiatry, & Psychology, 16(3), 255–259.
Flückiger, C., Wampold, B. E., Delgadillo, J., & Lutz, W. (2022). The importance of allegiance effects in psychotherapy research: A systematic review and meta‑analysis. Psychotherapy Research, 32(3), 277–290.
Foa, E. B., Dancu, C. V., Hembree, E. A., Jaycox, L. H., Meadows, E. A., & Street, G. P. (1999). A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. Journal of Consulting and Clinical Psychology, 67, 194-200.
Foa, E. B., & Rauch, S. A. M. (2004). Cognitive changes during prolonged exposure versus prolonged exposure plus cognitive restructuring in female assault survivors with posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 72(5), 879-884.
Foa, E. B., Rothbaum, B. O., Riggs, D. S., & Murdock, T. (1991). Treatment of posttraumatic stress disorder in rape victims: A comparison between cognitive‑behavioral procedures and counseling. Journal of Consulting and Clinical Psychology, 59, 715-723.
Forman‑Hoffman, V. L., Cook Middleton, J., Feltner, C., Gaynes, B. N., Palmieri Weber, R., Bann, C., … & Lohr, K. N. (2018). Psychological and pharmacological treatments for adults with posttraumatic stress disorder: A systematic review update. Journal of Traumatic Stress, 31(5), 661–678.
Frankl, V. E. (1959). Man’s search for meaning. Washington Square Press.
Frost, H., Campbell, P., Maxwell, M., O’Carroll, R. E., Dombrowski, S. U., Williams, B., … & Pollock, A. (2021). Effectiveness of behavioural activation for depression: A systematic review and meta‑analysis. Health Psychology Review, 15(1), 56–81.
Gaudiano, B. A. (2006). The “third wave” behavior therapies in context. Cognitive and Behavioral Practice, 13, 101–104.
Gaudiano, B. A. (2008). Cognitive‑behavioral therapies: Achievements and challenges. Evidence‑Based Mental Health, 11(1), 5-7.
Gaudiano, B. A. (2009a). A systematic review of the research on acceptance and commitment therapy. The Behavior Therapist, 32(6), 114-124.
Gaudiano, B. A. (2009b). Öst’s (2008) methodological comparison of clinical trials of acceptance and commitment therapy versus cognitive behavior therapy: Matching apples with oranges? Behaviour Research and Therapy, 47, 1066-1070.
Gaudiano, B. A. (2011). Evaluating acceptance and commitment therapy: An analysis of a recent critique. International Journal of Behavioral Consultation and Therapy, 7(1), 54-65.
Gloster, A. T., Walder, N., Levin, M. E., Twohig, M. P., & Karekla, M. (2020). The empirical status of acceptance and commitment therapy: A meta‑analysis of randomized controlled trials. Journal of Contextual Behavioral Science, 15, 52–62.
Goldberg, S. B., Tucker, R. P., Greene, P. A., Davidson, R. J., Wampold, B. E., Kearney, D. J., & Simpson, T. L. (2018). Mindfulness‑based interventions for psychiatric disorders: A systematic review and meta‑analysis. Clinical Psychology Review, 59, 52–60.
Gu, J., Strauss, C., Bond, R., & Cavanagh, K. (2015). How do mindfulness‑based cognitive therapy and mindfulness‑based stress reduction improve mental health and wellbeing? A systematic review and meta‑analysis of mediation studies. Clinical Psychology Review, 37, 1–12.
Hannum, R., Rosellini, R., & Seligman, M. (1976). Retention of learned helplessness and immunization in the rat from weaning to adulthood. Developmental Psychology, 12(5), 449–454.
Harris, L. (2002). Insurrectionist ethics: Advocacy, moral psychology, and pragmatism. In J. Howie (Ed.), Ethical issues for a new millennium (pp. 193-210). Southern Illinois University Press.
Hayes, S. C. (2004). Acceptance and commitment therapy, relational frame theory, and the third wave of behavior therapy. Behavior Therapy, 35(4), 639-665.
Hayes, S. C. (2008). Climbing our hills: A beginning conversation on the comparison of acceptance and commitment therapy and traditional cognitive behavioral therapy. Clinical Psychology: Science & Practice, 15(3), 286-295.
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.
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, 1–25.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. Guilford Press.
Herbert, J. D. (2005). Is ACT a cult? Is ACT just a fad? [PowerPoint presentation]. ACT Summer Institute, La Salle University. (Archived on ACBS website)
Herbert, J. D., & Padovani, A. (2022). Contextualism, psychological science, and the question of ontology. Journal of Contextual Behavioral Science, 23, 1–9.
Hinton, D. E., & Patel, A. (2017). Cultural adaptations of cognitive‑behavioral therapy. Psychiatric Clinics of North America, 40(4), 701–714.
Hofmann, S. G. (2008). Acceptance and commitment therapy: New wave or Morita therapy? Clinical Psychology: Science and Practice, 15(4), 280-285.
Hofmann, S. G. (2021). The evidence base of cognitive‑behavioral therapy: An updated commentary. Clinical Psychology Review, 89, 102080.
Hofmann, S. G., & Asmundson, G. J. G. (2008). Acceptance and mindfulness‑based therapy: New wave or old hat? Clinical Psychology Review, 28(1), 1-16.
Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta‑analyses. Cognitive Therapy and Research, 36(5), 427–440.
Hofmann, S. G., Curtiss, J., & Hayes, S. C. (2021). Third‑wave cognitive‑behavioral therapies. In D. H. Barlow (Ed.), The Oxford handbook of clinical psychology (2nd ed., pp. 456–478). Oxford University Press.
Hofmann, S. G., & Hayes, S. C. (2019). The future of intervention science: Process‑based therapy. Clinical Psychological Science, 7(1), 37–50.
Holtz, T. (1998). Refugee trauma versus torture trauma: A retrospective controlled cohort study of Tibetan refugees. Journal of Nervous and Mental Disease, 186(1), 24–34.
Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner, K., Gollan, J. K., et al. (1996). A component analysis of cognitive‑behavioral treatment for depression. Journal of Consulting and Clinical Psychology, 64, 295–304.
Kabat‑Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life. Hyperion.
Karyotaki, E., Efthimiou, O., Miguel, C., Maas genannt Bermpohl, F., Furukawa, T. A., & Cuijpers, P. (2021). Internet‑based cognitive behavioral therapy for depression: A systematic review and individual patient data network meta‑analysis. JAMA Psychiatry, 78(4), 361–371.
Kavaliers, M., & Choleris, E. (2001). Antipredator responses and defensive behavior: Ecological and ethological approaches for the neurosciences. Neuroscience and Biobehavioral Reviews, 25, 577-586.
Kazantzis, N., Luong, H. K., Usatoff, A. S., Impala, T., Yew, R. Y., & Hofmann, S. G. (2018). The processes of cognitive behavioral therapy: A review of meta‑analyses. Cognitive Therapy and Research, 42(4), 349–357.
Keane, T. M., Fairbank, J. A., Caddell, J. M., & Zimering, R. T. (1989). Implosive (flooding) therapy reduces symptoms of PTSD in Vietnam combat veterans. Behavior Therapy, 20, 245-260.
Krypotos, A. M., Effting, M., Kindt, M., & Beckers, T. (2015). Avoidance learning: A review of theoretical models and recent developments. Frontiers in Behavioral Neuroscience, 9, 189.
Kumar, V., Sattar, Y., Bseiso, A., Khan, S., & Rutkofsky, I. H. (2017). The effectiveness of internet‑based cognitive behavioral therapy in treatment of psychiatric disorders. Cureus, 9(8), e1626. https://doi.org/10.7759/cureus.1626
Leitan, N. D., Chaffey, L., & Hayes, S. C. (2015). The search for common ground between Morita therapy and acceptance and commitment therapy. Journal of Contextual Behavioral Science, 4(3), 171–176.
Lemmens, L. H., Müller, V. N., Arntz, A., & Huibers, M. J. (2016). Mechanisms of change in psychotherapy for depression: A systematic review. Clinical Psychology Review, 49, 1–11.
Levin, M. E., Hildebrandt, M. J., Lillis, J., & Hayes, S. C. (2017). The impact of treatment components suggested by the psychological flexibility model: A meta‑analysis of laboratory‑based component studies. Behavior Therapy, 48(1), 67–80.
Levin, M., & Hayes, S. C. (2009). Is acceptance and commitment therapy superior to established treatment comparisons? Psychotherapy and Psychosomatics, 78, 380.
Lilienfeld, S. O. (2017). Psychology’s replication crisis and the ‘allegiance effect’. Perspectives on Psychological Science, 12(5), 869–871.
Lima, S. L. (1998). Stress and decision‑making under the risk of predation: Recent developments from behavioral, reproductive and ecological perspectives. Advances in the Study of Behavior, 27, 215-290.
Linehan, M. M. (1993). Cognitive‑behavioral treatment of borderline personality disorder. Guilford Press.
Linehan, M. M., Korslund, K. E., Harned, M. S., & Gallop, R. J. (2015). Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: A randomized clinical trial and component analysis. JAMA Psychiatry, 72(7), 701-708.
Linehan, M. M., & Wilks, C. R. (2015). The course and evolution of dialectical behavior therapy. American Journal of Psychotherapy, 69(2), 97-110.
Livanou, M., Başoğlu, M., Marks, I. M., De Silva, P., Noshirvani, H., Lovell, K., & Thrasher, S. (2002). Beliefs, sense of control and treatment outcome in post‑traumatic stress disorder. Psychological Medicine, 32(1), 157-165.
Longmore, R. J., & Worrell, M. (2007). Do we need to challenge thoughts in cognitive behavior therapy? Clinical Psychology Review, 27, 173–187.
Lorenzo‑Luaces, L., German, R. E., & DeRubeis, R. J. (2021). Is cognitive restructuring a necessary component of cognitive‑behavioral therapy for depression? A systematic review. Behaviour Research and Therapy, 143, 103875.
Lynch, T. R., Chapman, A. L., Rosenthal, M. Z., Kuo, J. R., & Linehan, M. M. (2006). Mechanisms of change in dialectical behavior therapy: Theoretical and empirical observations. Journal of Clinical Psychology, 62(4), 459-480.
Marcus, D. K., O’Connell, D., Norris, A. L., & Sawaqdeh, A. (2014). Is the dodo bird endangered in the 21st century? A meta‑analysis of treatment comparison studies. Clinical Psychology Review, 34(7), 519–530.
Marks, I. M., Başoğlu, M., & Noshirvani, H. (1994). Cognitive therapy in panic disorder. British Journal of Psychiatry, 165, 556-557.
Marks, I. M., Başoğlu, M., & Noshirvani, H. (1995). Cognitive therapy for panic. British Journal of Psychiatry, 165(4), 541-542.
Marks, I. M., Lovell, K., Noshirvani, H., & Livanou, M. (1998). Treatment of posttraumatic stress disorder by exposure and/or cognitive restructuring – A controlled study. Archives of General Psychiatry, 55, 317-325.
Mavranezouli, I., Megnin‑Viggars, O., Daly, C., Dias, S., Welton, N. J., Stockton, S., … & Pilling, S. (2020). Psychological treatments for post‑traumatic stress disorder in adults: A network meta‑analysis. Psychological Medicine, 50(4), 542–555.
Mayo‑Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D. M., & Pilling, S. (2014). Psychological and pharmacological interventions for social anxiety disorder in adults: A systematic review and network meta‑analysis. The Lancet Psychiatry, 1, 368–376.
McLean, C. P., Levy, H. C., Miller, M. L., & Tolin, D. F. (2022). Exposure therapy for anxiety and PTSD: A meta‑analysis of therapist‑guided vs. self‑administered formats. Behavior Therapy, 53(4), 678–694.
Miga, E. M., Neacsiu, A. D., & Linehan, M. M. (2019). Dialectical behavior therapy for borderline personality disorder. In The Oxford handbook of dialectical behaviour therapy (pp. 15–32). Oxford University Press.
Mineka, S., & Zinbarg, R. (2006). A contemporary learning theory perspective on the etiology of anxiety disorders – It’s not what you thought it was. American Psychologist, 61(1), 10-26.
Monestès, J. L., & Villatte, M. (2013). Breaking the ontology taboo: Reply to Monestès and Villatte. Journal of Contextual Behavioral Science, 2(3-4), 55–60.
Munder, T., Flückiger, C., Gerger, H., Wampold, B. E., & Barth, J. (2019). The allegiance effect in psychotherapy research: A systematic review and meta‑analysis. Clinical Psychology: Science and Practice, 26(1), e12268.
Normann, N., Emons, B., & Morina, N. (2019). The efficacy of metacognitive therapy for anxiety and depression: A meta‑analytic review. Journal of Anxiety Disorders, 66, 102110.
Öst, L. G. (1987). Applied relaxation: Description of a coping technique and review of controlled studies. Behaviour Research and Therapy, 25(5), 397–409.
Öst, L. G. (2008). Efficacy of the third wave of behavioral therapies: A systematic review and meta‑analysis. Behaviour Research and Therapy, 46(3), 296-321.
Öst, L. G. (2009). Inventing the wheel once more or learning from the history of psychotherapy research methodology: Reply to Gaudiano’s comments on Öst’s (2008) review. Behaviour Research and Therapy, 47, 1071-1073.
Öst, L. G. (2014). The efficacy of acceptance and commitment therapy: A systematic review and meta‑analysis. Behaviour Research and Therapy, 61, 92-103.
Paunovic, N., & Öst, L. G. (2001). Cognitive‑behavior therapy vs exposure therapy in the treatment of PTSD in refugees. Behaviour Research and Therapy, 39, 1183-1197.
Pepper, S. C. (1942). World hypotheses: A study in evidence. University of California Press.
Powers, M. B., & Emmelkamp, P. M. G. (2009). Response to ‘Is acceptance and commitment therapy superior to established treatment comparisons?’ Psychotherapy and Psychosomatics, 78, 380–381.
Powers, M. B., Vörding, M., & Emmelkamp, P. M. G. (2009). Acceptance and commitment therapy: A meta‑analytic review. Psychotherapy and Psychosomatics, 8, 73-80.
Rathod, S., Gega, L., Degnan, A., Pikard, J., Khan, T., Husain, N., … & Naeem, F. (2018). The current status of culturally adapted mental health interventions: A practice‑focused review of meta‑analyses. Neuropsychiatric Disease and Treatment, 14, 165–178.
Rauhut, A. S., Thomas, B. L., & Ayres, J. B. (2001). Treatments that weaken Pavlovian conditioned fear and thwart its renewal in rats: Implications for treating human phobias. Journal of Experimental Psychology: Animal Behavior Processes, 27, 99–114.
Richards, D. A., Ekers, D., McMillan, D., Taylor, R. S., Byford, S., Warren, F. C., … & Finning, K. (2016). Cost and outcome of behavioural activation versus cognitive‑behavioural therapy for depression: A randomised controlled trial. The Lancet Psychiatry, 3(9), 831–840.
Rosenfield, D., Zhou, J., & Shafran, R. (2018). Cognitive‑behavioural therapy for anxiety disorders: A review of the evidence. In S. G. Hofmann & P. M. Asmundson (Eds.), The science of cognitive behavioral therapy (pp. 97–119). Academic Press.
Ruiz, F. J., Bianchi, J. M., Bastidas‑Suarez, D. M., Ramirez, E. S., & Pena‑Hernandez, V. (2024). Is the AAQ‑II that bad? Journal of Contextual Behavioral Science, 34, 100854.
Satterfield, J. M. (1998). Cognitive behavioral group therapy for depressed, low‑income minority clients: Retention and treatment enhancement. Cognitive and Behavioral Practice, 5(1), 65-80.
Scheel, K. R. (2000). The empirical basis of dialectical behavior therapy: Summary, critique, and implications. Clinical Psychology: Science and Practice, 7(1), 68-86.
Scholes, C., Turpin, G., & Mason, S. (2007). A randomised controlled trial to assess the effectiveness of providing self‑help information to people with symptoms of acute stress disorder following a traumatic injury. Behaviour Research and Therapy, 45, 2527-2536.
Seligman, M. E. P., & Maier, S. F. (1967). Failure to escape traumatic shock. Journal of Experimental Psychology: Animal Behavior Processes, 74(1), 1–9.
Stockton, D., Kellett, S., Berrios, R., & Sirois, F. (2019). The role of psychological flexibility in the relationship between rumination and depression. Journal of Contextual Behavioral Science, 14, 88–95.
Stoffers‑Winterling, J. M., Storebø, O. J., Simonsen, E., Jørgensen, M. S., Ribeiro, J. P., Kongerslev, M. T., & Lieb, K. (2022). Perspectives on dialectical behavior therapy and mentalization‑based therapy for borderline personality disorder: Same, different, complementary? Psychology Research and Behavior Management, 15, 3179-3189.
Szabo, T. G., & Tarbox, J. (2022). Beyond what “is” and what “is‑not”: Special issue on ontological and epistemological controversies in contextual behavioral science. Journal of Contextual Behavioral Science, 23, 1–4.
Teachman, B. A., McKay, D., & Olatunji, B. O. (2019). What is the appropriate role of cognition in cognitive‑behavioral therapy? Behavior Therapy, 50(3), 490–502.
Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgeway, V. A., Soulsby, J. M., & Lau, M. A. (2000). Prevention of relapse/recurrence in major depression by mindfulness‑based cognitive therapy. Journal of Consulting and Clinical Psychology, 68, 615–623.
Tolin, D. F. (2010). Is cognitive‑behavioral therapy more effective than other therapies? A meta‑analytic review. Clinical Psychology Review, 30(6), 710–720.
Tolin, D. F. (2014). Beating a dead dodo bird: Looking at signal vs. noise in cognitive‑behavioral therapy for anxiety disorders. Clinical Psychology: Science and Practice, 21(4), 351–362.
Tran, U. S., & Gregor, B. (2016). The relative efficacy of bona fide psychotherapies for post‑traumatic stress disorder: A meta‑analytical evaluation of randomized controlled trials. BMC Psychiatry, 16, 266.
Tyndall, I., Waldeck, D., Pancani, L., Whelan, R., & Roche, B. (2019). The Acceptance and Action Questionnaire‑II (AAQ‑II) as a measure of experiential avoidance: A systematic review and meta‑analysis. Journal of Contextual Behavioral Science, 15, 19–28.
Ujhelyi‑Gomez, K., Rushton, E., Harrison, J., & Hill, J. E. (2025). Dialectical behaviour therapy in the treatment of borderline personality disorder: A commentary. Mental Health Practice, 28(2).
Uluşahin, A., Başoğlu, M., & Paykel, E. S. (1994). A cross‑cultural comparative study of depressive symptoms in British and Turkish clinical samples. Social Psychiatry and Psychiatric Epidemiology, 29(1), 31-39.
van der Heiden, C., van der Meulen, K., & van der Molen, H. T. (2021). Cognitive behavioral therapy for patients with low educational level: A systematic review. Journal of Cognitive Psychotherapy, 35(2), 93–109.
Wampold, B. E., Flückiger, C., Del Re, A. C., Yulish, N. E., Frost, N. D., Pace, B. T., Goldberg, S. B., Miller, S. D., Baardseth, T. P., Laska, K. M., & Hilsenroth, M. J. (2017). In pursuit of truth: A critical examination of meta‑analyses of cognitive behavior therapy. Psychotherapy Research, 27(1), 14-32.
Wells, A. (1995). Metacognition and worry: A cognitive model of generalized anxiety disorder. Behavioural and Cognitive Psychotherapy, 23, 301–320.
West, C. (1989). The American evasion of philosophy: A genealogy of pragmatism. University of Wisconsin Press.
Williams, J., & Maier, S. (1977). Transsituational immunisation and therapy of learned helplessness in the rat. Journal of Experimental Psychology: Animal Behavior Processes, 3(3), 240–252.
Wolgast, M. (2014). What does the Acceptance and Action Questionnaire (AAQ‑II) really measure? Behavior Therapy, 45(6), 831–839.
Zilio, D. (2011). Some remarks on acceptance and commitment therapy (ACT) and the problem of values. Perspectivas em Análise do Comportamento, 2(2), 159–165.
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