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Roger Vilardaga and Steven C. Hayes, University of Nevada, Reno
Acceptance and Commitment Therapy and the
Therapeutic Relationship Stance
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ABSTRACT
This paper characterizes the ACT therapeutic relationship stance in the context of the find-
ings of the common factors literature and the relationship between therapeutic alliance
and outcomes. We describe some foundational aspects of the ACT model (its philosoph-
ical set of assumptions, its scientific theory of language and cognition, and its operating
system of clinical intervention) and how they form the ACT therapeutic relationship stance.
We also provide a possible theoretical model of the therapeutic relationship and a specif-
ic exercise to foster it that can be used by clinicians. Overall, we hold the therapeutic rela-
tionship as an important component of the therapeutic process and we argue that the ACT
model, as a contextual behavioral science strategic approach (VILARDAGA, HAYES, LEVIN, &
MUTO, 2009) provides a clearer understanding of the impact of the therapeutic relation-
ship on outcomes, together with a clearer rationale to both improve the therapeutic rela-
tionship and research it.
Keywords: therapeutic relationship, ACT, Contextual Behavioral Science, common factors,
deictic framing.
Acceptance and Commitment Therapy and the Therapeutic
Relationship Stance
Relating to another human being is hard. It takes effort, care, and skills to understand what it
is like to be another, and even when we do so, we may avoid the discomfort that it might entail
by pushing aside evident but unwanted thoughts, feelings and emotions or by not letting them
have full-fledged status in our experience. But relating to other human beings can also be a
source of joy, satisfaction and healing. It seems that the most intense experiences – positive
and negative – in a human life generally have to do with relating to others individually and in
groups.
Psychotherapy work occurs within the context of relating to others and thus, the pains and joys
described above also apply to the relationship between therapist and client. The therapeutic
relationship is also a process that can be difficult, on both sides, because it too evokes avoidant
responses of all kind of forms and sizes. When they are overcome, however, it is a relationship
that can lead to meaningful and transformative experiences.
In this paper, we will address this topic by examining the existing literature on the therapeutic
relationship and then presenting the therapeutic relationship stance of Acceptance and
Commitment Therapy (ACT; HAYES, STROSAHL, & WILSON, 1999). In the past, some authors have
written to the importance of the therapeutic relationship from a behavioral perspective (see
SWEET, 1984, for a review), but truly behavioral accounts of this relationship did not emerge
until the advent of a new generation of behavioral therapies (e.g., FOLLETTE, NAUGLE, &
CALLAGHAN, 1996; HAYES, KOHLENBERG, & MELANCON, 1989; HAYES & WILSON, 1993; HAYES &
WILSON, 1994; KOHLENBERG & TSAI, 1991) that took seriously the task of unpacking the behav-
ioral processes (both verbally and non-verbally) that take place between two individuals in a
therapeutic setting. The approach presented in this paper is part of this emerging tradition.
This paper is structured in the following way. First of all we will briefly review the literature on
the therapeutic relationship. Following that we will proceed to lay out the foundations of the
ACT model of intervention and how they have shaped the ACT therapeutic relationship stance.
Finally, we will summarize both literatures and will draw some conclusions.
Researchers have used different terms to refer to the therapeutic relationship: Therapeutic
alliance, therapeutic bond, working alliance, and so on. In view of some, the “therapeutic
alliance” and the “therapeutic relationship” are two different constructs (e.g., BALDWIN,
WAMPOLD, & IMEL,2007); others instead have interchangeably referred to both (e.g., LAMBERT
& BARLEY, 2001). In this paper we will follow this second approach.
The Therapeutic Relationship in the Clinical Psychology Literature
Interest in the therapeutic relationship or alliance has its origins in psychoanalytic theory, in par-
ticular in some brief references made by Freud (see HORVATH, 2001, for a more complete
description of the origins of this concept) to the importance of a cooperative relationship
between therapist and client and to the nature of that process. Freud argued that the bond
between therapist and client could be the result of the client’s identification of the therapist
with benevolent individuals in his/her past. It was not until the late 1970s and early 1980s that
the term alliance started to be adopted by therapists and researchers from multiple orienta-
tions (e.g., FORD, 1978; SALTZMAN, LUETGERT, ROTH, CREASER, & HOWARD, 1976; SWEET, 1984).
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This new construct was generally taken as “pantheoretical” and was viewed as an opportunity
for scientists from different theoretical models or schools to find common grounds and con-
form to an objective and scientific understanding of psychotherapeutic processes without get-
ting entangled in endless discussions of what therapy model was best.
One of the most influential conceptualizations of the therapeutic relationship was that of
BORDIN (1979), who published a seminal paper in which he described the therapeutic alliance
as a composite of three different aspects: a) the relational bond between therapist and client,
b) the tasks of psychotherapy, and c) the goals of psychotherapy (or the outcomes that are
sought). Bordin’s paper was very influential; in particular because he emphasized that there
can be many kinds of therapeutic alliances as long as their essential feature, the presence of
a shared purpose between therapist and client, was present. He also expressed concern over
the proliferation of psychotherapies and he stressed the potential role of the therapeutic
alliance research in order to advance the scientific understanding of the therapeutic process.
Bordin’s definition of the therapeutic alliance set the stage for the development of alliance
measures and a series of investigations about the relationship between alliance and outcomes.
In the last decades studies on the therapeutic alliance have abounded (e.g., ALLEN ET AL., 1986;
CASTONGUAY, GOLDFRIED, WISER, RAUE, & HAYES,1996; FRANK & GUNDERSON, 1990; GALLOP,
KENNEDY, & STERn, 1994; KRUPNICK ET AL., 1996). The extent of the literature allowed that two
impactful meta-analysis on the effect of therapeutic alliance on outcomes led to the conclu-
sion that there was a robust association between therapeutic alliance and therapy outcomes
(HORVATH & SYMONDS, 1991; MARTIN, GARSKE, & DAVIS, 2000). In HORVATH ETAL.’S(1991) meta-
analysis the combined overall weighted effect size of the working alliance on outcome after
reviewing 24 studies was .26 (as expressed with a Pearson correlation coefficient). MARTIN ET
AL.(2000) performed a more systematic and inclusive review of 79 outcome studies, found
that the averaged effect size of alliance on outcome was .22. Alliance was moderately related
to therapeutic outcomes and was a consistent predictor. Such results were consistent across
kinds of therapeutic alliance scales, sources of alliance reports, therapeutic approaches, and
types of disorders treated. Year of publication or methodological soundness of the studies had
no confounding effect on that relationship. The authors suggested that the therapeutic alliance
might be therapeutic in and of itself, although they clarified that there might be underlying
mechanisms that explain that relationship or interactions between alliance and some interven-
tions which given the characteristics of their analyses could not be ruled out (MARTIN ETAL.,
2000, p. 446). Horvath reported another meta-analysis with the inclusion of 90 clinical trials
and computed an averaged effect size of .21, which would correspond to a Cohen’s d of .45,
a medium-sized effect that would account for 5% of the variance on outcome (HORVATH AND
BENI,2002).
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BALDWIN AND WAMPOLD (2007) in a more fine grain analysis of the alliance-outcome relation-
ship found that therapists who formed stronger alliances with their clients tended to have bet-
ter outcomes that those who did not while client’s levels of alliance with their therapists were
not predictive of therapy outcome. They also found that early outcomes change was unrelat-
ed to therapist alliance, suggesting that the alliance was not a byproduct of treatment success.
The current state of the literature taken as a whole is that the relationship between working
alliance and outcome is consistent and within the range of the effect sizes of standard treatments.
As we noted, from the beginning (BORDIN, 1979), therapeutic alliance research has been linked
to the search for common factors in psychotherapy. Wampold et al. (1997), based on a meta-
analysis of psychotherapy outcomes, restated the Dodo Bird Effect, claiming that when treat-
ments designed to be effective are compared, their effect sizes approach zero. Wampold
argued that the emphasis of researchers on the specific components of psychotherapy mod-
els is due to the fact that psychotherapy has followed the medical model (a model for which
specificity is key), and in his opinion this model is slowing down the scientific progress of psy-
chotherapy (WAMPOLD, 2005; WAMPOLD, 2007). For Wampold most of the variance responsi-
ble for the effects of psychotherapy are aspects such as therapeutic alliance, alliance of the clin-
ician with the model that he proposes, therapist competence and placebo effects, and he has
reasoned that if we are to really understand the phenomena of psychotherapy we need to step
out from research focusing exclusively on outcomes and start paying more attention to com-
mon factors and processes of change (MESSER & WAMPOLD, 2002). Some have suggested that
the impact of the alliance on outcomes is greater than that of active bona fide treatments pack-
ages (MESSER ET AL., 2002). These claims and the methods used to arrive at them are contro-
versial and have sparked considerable debate (e.g. SIEV, HUPPERT, & CHAMBLESS, 2009; WAM-
POLD, IMEL, & MILLER,2009) but there is no doubt that the therapeutic alliance has emerged
as an important aspect of modern research into psychotherapy and has been conceptualized
as an alternative to the exclusive emphasis in outcomes of the literature.
A disturbing aspect of the current literature is that attempts to train therapists to have better
alliances with their clients have not yet been proven to be successful. There is no clear evi-
dence that adherence to alliance guidelines enhances therapy outcomes (CRITS-CHRISTOPH ET
AL., 2006) – indeed there is some evidence that it rather produces negative attitudes toward
clients (HENRY, SCHACHT, STRUPP, BUTLER, & BINDER, 1993). This suggests that the understand-
ing of the therapeutic relationship is not yet sufficient to lead to manipulable features that reli-
ably improve outcomes. Perhaps as a reflection of this concern well-known therapeutic alliance
researchers have argued that the field needs to put more emphasis on the theoretical devel-
opment of the therapeutic alliance as a construct. HORVATH (2005) when speaking to the chal-
lenges of the therapeutic alliance research stated that:
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“Firstly, we need more theoretical debate about the construct of the relationship. The rela-
tively brief period between the initial theoretical/conceptual formulation and the develop-
ment of measuring procedures that in practice defined the construct for research that fol-
lowed likely foreclosed the opportunity to examine the implications and possible limitations
of the concept as first presented by LUBORSKY (1976) and BORDIN (1979).” (p.4)
In a somewhat different vein, Bordin argued that the fact that many authors took the thera-
peutic alliance construct as a “pantheoretical” approach cut off from its psychoanalytic roots,
limited the theoretical development that might have occurred.
One alternative to investigate scientifically the therapeutic alliance is the model proposed by
some behavioral clinicians. FOLLETTE, NAUGLE AND CALAHHAN (1996) proposed that the basic
operant conditioning model (SKINNER, 1957) and Relational Frame Theory (HAYES ET AL., 2001)
could account for the alliance factors proposed by the alliance research. In their view a behav-
ioral analytical account that focuses on therapist-client interactions could be more adequate.
However, behavioral proponents have had a limited impact on the empirical literature in the
area.
At this point empirical methods to develop the therapeutic relationship are very limited.
BALDWIN ETAL.(2007) recommended validation techniques drawn from Dialectical Behavior
Therapy (LINEHAN, 1993); SAFRAN ETAL.(1994) suggested managing and dealing with client-
therapist ruptures as a way to nurture the alliance; LAMBERT ET AL.(2003) advocated for mon-
itoring systems of client-therapist alliance ratings; and finally ACKERMAN AND HILSENROTH (2003)
pursued the systematic identification of therapist qualities that foster the therapeutic relation-
ship. Some of the suggestions entail adoption of different empirical traditions than mainstream
empirical clinical science. For example, WAMPOLD (2006) proposed that a viable venue for the
study of non-specific factors is anthropology and the cultural aspects of the psychotherapy pro-
cess. As we have argued elsewhere (VILARDAGA & HAYES, 2009), some of these changes would
risk losing the psychological unit of analysis, which is the prediction and change of the behav-
ior of the individual in a historical and situational context. There are no examples we know of
in which such a form of science has proven useful to psychological intervention.
All in all, the scientific and empirical investigation of how to foster the therapeutic alliance is still
in its early stages. For research in this area to be successful, conceptual clarity, methodological
creativity, and a coherent focus on the development of useful approaches are necessary.
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The ACT Therapeutic Relationship Stance
ACT as a model of intervention revolves around the notion of psychological flexibility, a func-
tional diagnostic dimension and model of psychopathology. The ACT model argues that the
core of human suffering lies in entanglement with the literal qualities of human cognition
resulting unwillingness of individuals to remain in contact with particular private experiences
(HAYES, WILSON, GIFFORD, & FOLLETTE, 1996, p. 1154), inability to maintain flexible and volun-
tary contact with the present, excessive attachment to a conceptualized self, and the failure to
engage in flexible and committed values-based action. Evidence for the importance of psy-
chological flexibility and its components in a variety of clinical problems and their mediational
role in clinical trials is increasing (HAYES ET AL., 2008; HAYES, LUOMA, BOND, MASUDA, & LILLIS,
2006).
PIERSON AND HAYES (2007) described the therapeutic relationship stance with an analysis of the
ACT processes at the levels of a) client, b) therapist, and c) their relationship. In their account
of the therapeutic relationship from an ACT point of view they laid out the importance of psy-
chological flexibility in all of its different dimensions and how that guides the decision making
process in ACT.
We will take a slightly different approach in the present paper. ACT is a model of clinical inter-
vention but it is also part of a larger effort that can be useful in understanding the therapeutic
relationship and its potential. ACT is one aspect of a deliberate strategy of scientific develop-
ment that we have come to term contextual behavioral science (CBS; HAYES, LEVIN, PLUMB,
BOULANGER, & PISTORELLO, 2008; LEVIN & HAYES, 2008; VILARDAGAETAL., 2009). Contextual
behavioral science emphasizes the use of multiple fronts of exploration as a way to strength-
en the epistemological power of our observations and thus to increase our chances to build
more progressive and useful technologies.
CBS is not a series of steps because its aspects are not linear or sequential. Rather it is an induc-
tive, iterative, reticulated development strategy with several simultaneous distinct fronts, among
them philosophical refinement, development of more useful basic processes, development of
clinical processes linked to a basic account, organization of processes into a broadly useful clin-
ical “operating system,” process research, component research, exploration of breadth of out-
come, dissemination and training, and the creation of a developed community of practitioners
and researchers. CBS per se is not the focus of the present paper, but we will review a few of
its key aspects as they become relevant to the present purpose. In this paper we will examine
the role of the therapeutic relationship using three different dimensions of the ACT model as a
form of contextual behavioral science: its philosophical assumptions, its basic theory of language
and cognition, and general aspects of ACT as an operating system of clinical intervention.
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The ACT Therapeutic Relationship Stance at the Level of Its Philosophical
Assumptions
In order to understand ACT as a model of intervention, it is helpful to start with its philosophi-
cal foundation (VILARDAGA, HAYES, & SCHELIN, 2007), which is known as functional contextual-
ism. Functional contextualism begins with the assumption that the world is an undivided and
undistinguished whole which we partition by virtue of interacting in and with it (HAYES, 1993).
Away from a solipsistic ontological stance functional contextualism takes the view that the world
is “real” in the sense of being one world, but as living creatures live in and with it, it becomes
non-arbitrarily structured in a plurality of ways.
Historically contextualism has had a difficult time not devolving into elemental realism on the
one hand, or mysticism on the other. If utility is justified by an appeal to ontology, the former
is likely because if the structure of reality is the basis of workability, truth is not a matter of con-
sequences per se but of its foundation in what is pre-organized and real. That idea, leads direct-
ly to elemental realism. If utility is justified by an appeal to personal sense of appreciation of
the whole (see HAYES, 1993), the latter is likely. This can lead to an initial phase of pointing out
the assumptions underlying all claims to knowledge (as in post-modernism), but ultimately one
begins to feel that any knowledge claim violates contact with the sense of the whole. True
knowledge thus means saying less and less about more and more: those who know do not
speak; those who speak do not know. That is a core assumption of mysticism.
In all forms of contextualism “truth” is any analytic division or formulation of the world that is
useful, but as a philosophy of science “useful” needs to be linked to assessable claims.
Functional contextualism is based on a refinement in this area: What is useful or pragmatic is
precisely that which allows us to achieve our analytic goals. Goals must be established a pri-
ori since they make sense of any epistemological effort to build knowledge and produce
change. In the absence of clear pre-analytic goals, successful working collapses into the behav-
ioral concept of reinforcement and the evolutionary concept of survival. These concepts do
indeed help explain how living creatures partition the world, but they are inadequate as scien-
tific guides since they fail to deal with the social and verbal nature of science and its attempt
to maximize contact with the world and limit the role of idiosyncratic histories in the determi-
nation of the utility of verbal knowledge (the central purpose of “the scientific method”).
The particular goal of functional contextualism is prediction and influence with precision, scope,
and depth. The goals and values of the researcher and practitioner of trying to manipulate and
influence the world are central in functional contextualism but in addition ways of speaking are
sought that allow these analytic purposes to be accomplished with specificity, that are broadly
applicable, and that do not contradict useful ways of speaking at other levels of analysis.
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The specification of analytic goals provides a middle path for contextualists. Workability need
not be caught up in truth by correspondence ontological claims, and it can be sensitive to the
purposes of the analyst and still be stated and shared.
Functional contextualism gives coherence to the ACT model of intervention. It provides an
overarching philosophical framework that allows ACT therapists to flexibly apply the model with-
out taking it to be “true” in a traditional ontological sense. This is helpful in maintaining a func-
tional approach. ACT is a set of principles not a set of techniques. For example, one of the
metaphors frequently employed by the ACT model is the Man in the hole (see HAYES ET AL.,
1999). This metaphor provides a verbal context that increases the likelihood that the client will
contact how unfruitful are his/her attempts to control and change uncomfortable thoughts,
feelings, physical sensations and wants. However there is nothing in the ACT model that pre-
vents the practitioner using any other metaphor in order to produce the same result, since we
need to take into account that given that every individual has a different history and circum-
stances, certain metaphors might evoke responses that are contrary to the ones we expected
(i.e., an individual that has a history of phobia to close and dark places). Similarly, a therapist’s
particular history of learning might cause the presentation of a particular metaphor less likely
to be effective.
A functional contextualist stance deemphasizes form over function by orienting the therapist to
the fact that any technique or concept is just one method to partition the world in order to help
the client and therapist accomplish their goals. This idea also has implications for how we con-
ceptualize the therapeutic relationship in ACT. Like all concepts, the notion of the “therapeutic
relationship” is not solidified or static. At most, it is a way of speaking that orients the therapist
or researchers to talk about a particular kind of phenomena in a way that is useful.
The “ideal” therapeutic relationship in ACT can be anything from a superficial and straightfor-
ward relationship, to one that is more intimate and profound. Both sides of the spectrum are
legitimate forms of therapeutic alliance, since for the functional contextualist, it is not the form
or topography of a particular relationship, but the fact that it functions to satisfy the goals and
values of both participants of that relationship. The resulting effect of lack of clarity in the goals
and values of the therapist and client is chaos and confusion. A “world” (or therapeutic rela-
tionship) in which the therapist and client do not share the same therapy goals, is a world in
which the differentiation and interpretation of psychological events is probably not going to
serve the purposes of both individuals.
BORDIN’S(1979) influential conceptualization of the therapeutic alliance, later on adopted by
most researchers in that area, seemed to favor some of the assumptions of functional contex-
tualism. This author underscored the importance of the agreement on goals between therapist
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and client, and as mentioned earlier, the goals of the therapist and client orient them to what
is it that they are predicting and influencing. This philosophical framework organizes the thera-
pists’ experience in the process of predicting and influencing behavior. By emphasizing the
goals of client and therapist we avoid “cartoon” versions of the alliance in which for example
we ought to feel “connected”. Instead, “connectedness” is always a function of what matters
for client and therapist, regardless of form.
This approach provides more flexibility to the specific ways in which we ought to behave when
relating to clients. We do not need to suppose that we always need to be intimate and close,
nor that this kind of relationship must be inherently therapeutic in and of itself. What’s thera-
peutic instead is that the client and therapist build a common set of goals and values and
based on them they construct their own therapeutic relationship around them.
The ACT Therapeutic Relationship Stance at the Level of Its Basic Theory
Along with behavioral principles, Relational Frame Theory (RFT; HAYES ET AL., 2001), a scientif-
ic theory of human language and cognition, is the core basic analysis that underlies the ACT
model. RFT has shown that it is helpful to think of language in terms of a core behavior called
arbitrarily applicable relational responding that consists in abstracting types of relations
between two events and bringing them under the control of arbitrary contextual cues. For
example, if we learn that when someone says “house” we might then see a HOUSE, we may
also be able to derive the spoken response “house” upon seeing a HOUSE. When a number
of functional sets of relational responses are abstracted, they form what are called relational
frames. The example presented above could be an example of “coordination framing,” but
there are other types of framing such as hierarchical framing, distinction framing, comparison
framing, etc.
One kind of relational framing that is particularly relevant for the therapeutic relationship is deic-
tic framing. This type of relational responding specifies some sort of relation in terms of the
perspective of the speaker. During a clinical session, if a client says “my car is broken”, the ther-
apist will have to derive a deictic relation of I-YOU in order to respond effectively to the frame
of coordination “car is broken”. “My” in that case refers to the perspective of the client, and not
to the therapist’s. But notice that the words “my”, or “mine” or “I” or “you”, unlike other kinds
of words, do not have a stable physical correlate. Their meaning will always depend on the per-
spective of the speaker.
Deictic framing thus, is constantly mediating our daily social interactions, and we have reasons
to suspect that when we use the words “relating to another person,” the kind of relating that
we are referring to is literally a form of deictic framing. An emerging body of literature suggests
that this process is associated to a variety of complex phenomena such as social anhedonia
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(VILLATTE, MONESTES, MCHUGH, FREIXA I BAQUÉ, & LOAS, 2008), empathy and stigma (VILARDAGA
ET AL., 2008), schizophrenia (VILLATTE, MONESTES, MCHUGH, FREIXA I BAQUÉ, & LOAS, 2009),
Theory of Mind performances (REHFELDT, DILLEN, ZIOMEK, & KOWALCHUK, 2007), and false belief
and deception (MCHUGH, BARNES-HOLMES, & BARNES-HOLMES, 2004). The link between deictic
framing and the therapeutic alliance seems arguably clear, and we would expect that the
strength of our operant ability to derive deictic framing relations will be directly associated to
the strength of the therapeutic alliance between client and therapist.
A theoretical path to explain the role of deictic framing in fostering the therapeutic relationship
can be viewed in figure 1. In this diagram we distinguish three different kinds of deictic pro-
cesses and their psychological effects. Suppose that in step 1, basic deictic relations are strength-
ened. A procedure to achieve that would be to ask multiple variations of questions such as “If I
were you where would I be?” or more complex forms such as “if I were you and here was there,
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Figure 1. A three levels path to increase psychological flexibility and foster the therapeutic relation-
ship
where would I be if I were there?” Decitic relations of this kind seem to result in an increased
ability to take the perspective of others. In step 2, deictic questions would be presented to help
the individual produce emotional responses. These questions would be variations of “How
would you feel if you were Kate?” or “How would it be like to be your brother?” Those questions
would prompt individuals to apply perspective taking skills to what another person feels, which
could result in a change in the targeted subject’s ability to experience more intense emotions
towards others. This second step seems necessary; since being aware of someone else’s private
experience (i.e., acknowledging that someone is sad) is not the same that privately responding
to them (i.e., feeling sad for someone else’s sadness). However, training this ability, as a result,
might lead to a variety of responses, depending on other skills. For example, empathy toward
others could easily lead to experiential avoidance or client depersonalization: Feeling everyone
else’s pain is something that most people might want to run away from or minimize and reduce
its importance. For that reason we hypothesize that a final step 3 in necessary, which consists
in helping the individual to take perspective with regards his own uncomfortable private events,
which is one of the aspects addressed by ACT under the rubric of self-as-context.
These three levels of intervention might suggest a new path not only to reducing therapist’s
depersonalization of their clients and increasing their empathic concern, but also to the foster-
ing of psychological flexibility and general well being.
In order to understand the significance of this process we need to address the notion of self-
as-context, which is a key ACT concept. Technically speaking, self, from a behavioral perspec-
tive, refers to one organism’s discrimination of its own behavior. Skinner, in his writings, intro-
duced the notion of self from a behavioral standpoint (e.g., SKINNER, 1974). If an organism
responds to situational events as a function not only of antecedent stimuli but also of his own
previously displayed behaviors (i.e., picking the green light to obtain food as a function of hav-
ing picked the red light before), we can assume that a discrimination of his own behavior has
occurred. The organisms’ own behavior becomes an antecedent stimulus for a subsequent
response that will be more likely to be reinforced. But the process of self-discrimination occurs
in a different fashion among humans (DYMOND & BARNES, 1995; DYMOND & BARNES, 1997): A
human organism is “not simply behaving with regard to his behavior, but is also behaving ver-
bally with regard to his behavior” (HAYES ET AL., 1993, p.297).
Self discrimination of our own behaviors, thoughts, feelings, wants and body sensations, over
deictic relations of time and space (I-YOU-HERE-NOW, I-YOU-THERE-NOW, I-YOU-HERE-THEN,
I-YOU-THERE-THEN), might lead to the formation of not just of one’s identity or self as an indi-
vidual but also to that of others (YOU). Our self-awareness is made of the constant stream of
this self-discrimination process. Based on the different levels of self-discrimination of our own
behaviors, thoughts, feelings, wants and bodily sensations (which for the sake of simplicity we
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will call from now on “private events”), the ACT model has distinguished three different kinds
of self: self-as-concept, self-as-process and self-as-context. A more detailed description of those
different kinds of self can be found elsewhere (e.g., BARNES-HOLMES, STEWART, DYMOND, &
ROCHE, 2000; HAYES, 1984; HAYES & GREGG, 2001). As reasoned in the ACT literature, self-as-
context involves the highest levels adaptability to the environment, since the “object” of dis-
crimination is a constant, but ineffable perspective that is dependent neither on the momen-
tary stream of private events nor on current overt actions. The implications of this approach are
that an inductive scientific analysis of human behavior provides the basis of ideas of self that
are cohesive, parsimonious, and susceptible to empirical investigation (HAYES, 1984).
In summary: RFT suggests that when we relate to our clients we engage in a form of relation-
al responding called deictic framing that can be trained at three different levels of complexity.
Secondly, the “what” or content of what is related are both our sense of self and our sense of
others, in other words, our self/other-discriminations of behaviors and private responses.
RFT informs the ACT model by suggesting that in order to enhance the therapeutic work and
our relationship with our clients, it is of vital importance that a functional discrimination of our
own thoughts, feelings and body sensations and that of others be established, since this is the
substance (what’s being related) of interpersonal relationships. That is why the ACT commu-
nity has from its inception encouraged practitioners of that model to participate in experiential
and not merely didactic trainings. These training events are designed to empower the clinician
by setting up an appropriate context in which he/she will be more likely to self-discriminate
his/her own behavior and private events (and that of other individuals) and contact a more
stable sense of self or self-as-context that can be linked to greater psychological flexibility.
As indicated earlier in this paper, some studies have shown that the therapists’ report of alliance
with their clients was more predictive of outcome than the client’s report of alliance with their
therapists (BALDWIN ETAL., 2007). In line with this finding, and based on our knowledge of RFT,
the exercise that we display in Figure 2 provides an example of how this idea might be applied.
This exercise can be used at the beginning of each session and should not take more than 4
minutes. The exercise is a visualization task based on what we know of our client (or in the
absence of that, on our intake information or brief telephone note). Each instruction consists
in taking a series of perspectives that begins with our client’s life, and transitions to the thera-
pists’ life. Instruction 1 consists in contacting the client’s spatial perspective (YOU-HERE-
THERE). Instruction 2 is a verbal prompt to contact the client’s private experience. Instruction
3 consists in contacting the client’s temporal perspective (YOU-NOW-THEN). Instruction 4
prompts the therapist to contact the client’s other-as-context. Instruction 5 prompts the thera-
pist to contact some of his own verbal barriers to empathize with his client (I-HERE-NOW).
Finally, the content of those is used in instructions 6, 7, 8, 9 and 10 to guide the therapist
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R. Vilardaga, S.C. Hayes: The ACT Therapeutic Relationship Stance (page xx-xx)
through parallel deictic framing manipulations in order to achieve a higher level of therapeutic
flexibility or alliance with his particular client.
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Figure 2. A deictics framing exercise to foster the therapeutic relationship previous a therapy ses-
sion*.
This is an exercise that should take between 1-4 minutes. Before starting the exercise, try to
find a quiet place (like your therapy room), and relax. The questions are not necessarily
intended to have a response; instead we encourage you to think through them. After each
question, please keep track of them marking the box on the left.
1. Take a few seconds and imagine you are your client on his/her way to the session. What
would he/she see, hear and smell on his/her way here? What would it be like sitting on
the waiting room before starting the session?
2. From this perspective of being your client, imagine what thoughts, feelings and judgments
he/she is having (if this is your first session, think about his/her presenting problem).
3. Notice the historical nature of these reactions. He/she has had those thoughts, feelings and
judgements for months or years, and in many different places, and they are likely to hap-
pen here, today.
4. In addition to his/her thoughts, feelings and judgements, see if you can connect with
his/her sense of conscious awareness that is more than the content of his/her suffering.
5. Try to recall some emotions, thoughts and judgments that you have had about your client
in the past (if this is your first session, think about his/her presenting problem).
6. Recall other times when similar thoughts, feelings and judgments have come up for you in
different therapy rooms or locations (maybe with different clients), months or years ago,
and notice how they are happening here, in this very moment.
7. In addition to these thoughts, feelings and judgements, see if you can connect with your
own sense of conscious awareness – you are more than the content of your reactions.
8. Now bring your attention back to when you decided to be a therapist. What were your
thoughts and feelings about being a therapist? What are your thoughts and feelings about
being a therapist now?
9. If you were transported five years into the future, what would you like this client to have
taken from the work the two of you have done?
10.Now bring your attention back to the room. Take a moment to just notice your different
bodily sensations … the various sounds… and the objects around you.
*Developed by Vilardaga, Levin and Hayes, 2007
The ACT Therapeutic Relationship Stance at the Level of its Operating System
The ACT model can be usefully viewed as an “operating system” that allows the practitioner to
apply principles and behavioral theories investigated at a more basic level to clinical phenom-
ena of higher complexity. One way of representing the ACT model is with a hexagon in which
each corner contains one psychological process. The six processes are: defusion, acceptance,
present-moment, self-as-context, values and committed-action. The purpose of this model is
to orient the clinician towards phenomena of clinical interest. Those processes are not highly
precise terms, nor highly abstracted categories; instead they are middle-level terms, allowing a
transition from highly precise behavioral principles and theories into more abstracted categories
that facilitate their application (VILARDAGAETAL., 2009). The effect of enhancing those six pro-
cesses through therapeutic work is psychological flexibility, which is the overall goal of ACT
interventions. A more detailed account of the ACT operating system and its components can
be found elsewhere (HAYES ET AL., 2006; HAYES, STROSAHL, & WILSON, in press).
The notion of psychological flexibility is key to understand the ACT therapeutic relationship
stance. It influences all the different aspects of the therapeutic relationship: the goals that client
and therapist have agreed upon, the tasks that they will put themselves to work, and the res-
olution of eventual ruptures in their relationship.
Psychological flexibility can take the form of different psychological processes. For example,
psychological flexibility is present when the therapist or client is able to be fully aware of the
noises, colors and smells of the therapy room while at the same time being aware of the move-
ments and oscillations of his private experiences (emotional reactions, random thoughts, wish-
es and desires, etc.). When the therapist or client is also fully aware of each other’s reactions,
gestures, physical properties, etc., ACT calls that process being in the present moment.
Psychologically flexible is also the willingness to have uncomfortable thoughts, feelings and
judgments towards our clients, or the client’s willingness to have uncomfortable thoughts, feel-
ings and judgments towards us. This form of psychological flexibility can be seeing as being
accepting. When the client or therapist do not get caught by the credibility and appearance of
ultimate reality provided by particular judgments (i.e., about themselves or the client or thera-
pist), they are able to take a relative stance towards them and remind themselves that they are
just part of their experience (i.e., as for example by telling themselves that in the same way
that they have arms and legs, they also have constantly changing thoughts and feelings towards
their therapist or client), the ACT therapist can label this process as being defused.
If the client and therapist are in contact with what they care about the most in life, and that
translates into being aligned on what they have agreed with each other to work towards to in
their therapeutic sessions, that itself is an aspect of psychological flexibility: contacting chosen
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goals and values. In addition, if the client and therapist not only know what they care about,
and hold the same therapeutic goals, but also actively engage in them both within the room
and/or outside of the session, that form of psychological flexibility is called being committed.
Finally, when client and therapist perceive themselves and each other not as the contents or form
of their body, or private events, nor as to their succession or change, but instead they perceive
themselves as a constant and invariant perspective that notices and experiences them, the ACT
therapist might call this form of psychological flexibility as being in a state of self/other-as-context.
The above paragraphs contain all the ACT middle-level terms in a nutshell. Since ACT is a prin-
ciple based therapy and not the application of a set of techniques, the ACT processes described
above can be flexibly used with the purpose of describing and defining the ACT therapeutic
relationship without violating its theoretical and philosophical coherence.
One aspect of the ACT model that also informs the therapeutic relationship refers to the way
ACT conceptualizes the notion of suffering. ACT assumes that suffering in one form or other is
a ubiquitous phenomenon that affects both clients and therapists. The RFT account of human
language and cognition supports the above statement. Verbal behavior once learned is very
resistant to extinction. Skinner actually argued that extinction barely occurs, and that under the
appropriate contextual factors, private events never experienced for years can promptly emerge
in full form (SKINNER, 1957). The notion of derived relational responding gives a more techni-
cal account of that process, and shows that events or objects never experienced can evoke
uncomfortable thoughts, feelings and memories in virtually any situation. Suffering thus, is
embedded in what makes us more human, which is language and cognition.
Suffering contacted willingly is a source of life information that enhances our ability to connect
with our clients. ACT views clinical work as a collaborative effort. In that sense it is not different
from the overall cognitive behavioral tradition, but ACT goes one step beyond by encouraging
the therapist to achieve the same psychological flexibility that he asks from his clients and to
use his own suffering to fuel the six ACT processes in himself. Among other reasons, that is
why ACT is called an experiential approach.
An intervention that is sometimes used at the beginning of therapy is the Two mountains
metaphor. The therapist, after clarifying its role in the therapeutic process and emphasizing how
the experience of suffering is shared with the client, might say:
“It’s like you’re in the process of climbing up a big mountain that has lots of dangerous
places on it. My job is to watch out for you and shout out directions if I can see places you
might slip or hurt yourself. But I’m not able to do this because I’m standing at the top of
your mountain, looking down at you. If I’m able to help you climb your mountain, it’s
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because I’m on my own mountain, just across a valley. I don’t have to know anything about
exactly what it feels like to climb your mountain to see where you are about to step, and
what might be a better path for you to take.” (TWOHIG, 2004, p.4).
This quote taken from an ACT protocol for individuals diagnosed with obsessive-compulsive
disorder is fully representative of the ACT therapeutic relationship stance. It sometimes hap-
pens that therapists adopt the attitude of mere professional providers of techniques or strate-
gies to ameliorate their client’s suffering. However, regardless of the fact that it is true that we
need to be professional in our work with clients, it is also truth that our duty as clinicians are
nevertheless to be genuine and authentic in our interactions with them. Pain and suffering is
an undeniable part of the human experience and embracing these phenomena can be a pow-
erful boost of the therapeutic alliance. The claims of the common factors literature summarized
at the beginning of this paper support the utility of this aspect of the ACT therapeutic relation-
ship stance.
Summary and Conclusions
The ACT therapeutic relationship stance is not an ad-hoc component of this model of inter-
vention. Instead, it emerges as the natural result of the converging effect of its philosophical
assumptions (Functional Contextualism; HAYES, 1993), a scientific theory of language and cog-
nition (Relational Frame Theory; HAYES ET AL., 2001), and finally, the characteristics and guiding
principles of the ACT model as an operating system for clinical intervention (Acceptance and
Commitment Therapy; HAYES ET AL., 1999). Those different fronts of exploration constitute a
form of scientific inquiry: contextual behavioral science (HAYES ET AL., 2008; LEVIN ETAL., 2008;
VILARDAGA ET AL., 2009).
The ACT therapeutic relationship stance encompasses a broad range of therapeutic relation-
ships; flexibility as to what is a proper and adequate therapeutic relationship between client
and therapist is central. In that regard, agreement on goals and values between client and ther-
apist is key, because those are defining features of the kind of relationship that will be built
between two individuals. Chaos and confusion emerges in the absence of clearly defined goals
and values. Second of all, a relationship between two individuals can be better understood as
a form of relational responding called deictic framing. The notion of deictic framing has pro-
found implications for our understanding of human interactions because they might be at the
core of what human interactions are, which is the act of taking perspective regarding other indi-
viduals and ourselves. Deictic framing can be devised as a powerful heuristic to develop new
interventions to foster the therapeutic relationship and research it. Furthermore, it can also pro-
vide a new venue for the scientific investigation of the formation of our identity as individuals
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R. Vilardaga, S.C. Hayes: The ACT Therapeutic Relationship Stance (page xx-xx)
and their implications for psychopathology. Finally, the ACT model, as an operating system of
clinical intervention contains elements that are allies of the therapeutic relationship, such as its
emphasis on the ubiquity of human suffering and its radically (at the root) collaborative stance.
Overall, the ACT therapeutic relationship stance converges with the guidelines and recom-
mendations presented by the therapeutic alliance movement (HORVATH, 2001; HORVATH, 2006)
and the recent emphasis on the non-specific or common factors of psychotherapy (MESSER ET
AL., 2002; WAMPOLD, 2007), but without abandoning an experimental and outcome focus.
Wampold criticized the existence of different psychotherapy models or schools on the grounds
that they are all equivalent in terms of outcomes (WAMPOLD ET AL., 1997). He also argued that
the reason for the existence of specific treatments for specific problems is that psychotherapy
has been subsidized by the medical model (MESSER ET AL., 2002; WAMPOLD, 2005). But the
ACT model could hardly be considered as derivative of the medical model (e.g., HAYES, WALSER,
& FOLLETTE, 1995), and although it is a distinct model of therapeutic intervention, it is not pre-
cisely of the kind that considers that only specific technological components can address spe-
cific syndromal problems. Instead, it is meant as a unified model of human behavior change
and psychological growth. With very few modifications it has shown to be effective for a vari-
ety of problems such as depression, anxiety, substance use, psychosis, borderline personality
disorder, trichotillomania, epilepsy, weight maintenance, and diabetes management (BACH &
HAYES, 2002; DALRYMPLE & HERBERT, 2007; GRATZ & GUNDERSON, 2006; GREGG, CALLAGHAN,
HAYES, & GLENN-LAWSON, 2007; HAYES ET AL., 2004; LILLIS, HAYES, BUNTING, & MASUDA, 2009;
LUNDGREN, DAHL, & HAYES, 2008; WOODS, WETTERNECK, & FLESSNER, 2006; ZETTLE & HAYES,
1987).
That would conform with some of Wampold’s claims, but not because we think that common
factors have any magical effect on people’s lives. Rather the source of the breadth is the fact
that human language and cognition in involved with all complex forms of human behavior and
useful concepts in that domain inherently spread across various problem areas. ACT is ground-
ed in a scientific tradition that has shown to have a broad impact in a variety of problems of
human concern such as education (e.g., JOHNSON & LAYNG, 1992; LAYNG, TWYMAN, &
STIKELEATHER,2004), organizational management (e.g., GLENN & MALOTT, 2004; MALOTT,
SHIMAMUNE, & MALOTT, 1992), autism and special education (e.g., CHARLOP-CHRISTY, CARPENTER,
LE, LEBLANC, & KELLET, 2002; LEBLANC ET AL., 2003), and behavioral economics (e.g., HURSH,
1984; JOLLS, SUNSTEIN, & THALER, 1998). The scientific strategy followed by ACT and contextu-
al behavioral science is the one of attempting to develop a comprehensive and scientific
account of human functioning that generates rules or principles of generalization with enough
precision, scope and depth to be able to be applied to a variety of problems in a variety of
ways. That goal is not justified by an a priori claim that the world is so organized as to make
this possible. None of us know how the world is organized beyond our interactions in and with
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it, and these interactions are always limited by history and purpose. It adds nothing to the use-
fulness of scientific ideas to claim that the reason they are useful is that they correspond to the
way the world is organized, but it also adds nothing to the usefulness of scientific ideas to fail
to seek the kind of utility we most deeply desire. ACT and the CBS tradition is attempting a
new way forward that is both bold and humble. This approach to the therapeutic relationship
we hope is an example.
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R. Vilardaga, S.C. Hayes: The ACT Therapeutic Relationship Stance (page xx-xx)
Correspondence address:
Roger Vilardaga
Department of Psychology / 298
University of Nevada, Reno
Reno, NV 89557-0062
Email: roger.vilardaga@gmail.com
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European Psychotherapy/Vol. 9 No. 1. 2009
