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Our commentary on the article by Fixsen and Blase (2018) highlights some of the converging and diverging strategies between the Teaching-Family Model (TFM) and the dissemination and implementation of acceptance and commitment therapy (ACT). We focus primarily on the potential benefits of flexibility in areas including theory, methodology, and intervention protocols. Examples include the use of middle level terms, randomized controlled trial methods, protocols focused more on function than specific topography, and an open, collaborative approach to dissemination. We also note how this broader set of strategies can be made coherent and progressive through a careful connection back to contextual behavioral science as an underlying scientific strategy and its associated philosophy of science. We hope this approach contributes to an ongoing conversation on potentially useful strategies for dissemination and implementation. THE BENEFITS OF FLEXIBILITY 3 The potential benefits of flexibility for dissemination and implementation: Acceptance and commitment therapy as an example The article by Fixsen and Blase (2018) provides a clear roadmap for how to scale up behavior analytic procedures for successful dissemination and implementation. The authors outline the steps taken and lessons learned in achieving large scale implementation through strategies such as focusing on fidelity, replication, and larger units of analysis with a welldefined set of procedures and programs. Identifying factors that affect successful dissemination and implementation is critically important to ensure decades of careful research have maximal impact on providers, policies, and, ultimately, public health. Yet, there may be multiple pathways to success and exploring other strategies can broaden the range of methods from which to choose. In this commentary, we will highlight some of the converging and diverging strategies between the Teaching-Family Model (TFM) and the dissemination and implementation of acceptance and commitment therapy (ACT). ACT is a behavior analytic approach to psychotherapy that has had notable success with dissemination over the past two decades, which we will review briefly for context. For example, the larger professional organization, the Association for Contextual Behavioral Science (ACBS), of which ACT is a central component, has over 7,000 members internationally and a flagship journal (Journal of Contextual Behavioral Science). ACT is recognized as an evidence-based treatment by organizations such as Division 12 of the American Psychological Association (APA, 2016) and the National Registry of Evidence-based Programs and Practices (SAMHSA, 2010). Searching “acceptance and commitment therapy” on PsychInfo identifies over 1,300 peer-reviewed articles, and over 250 randomized controlled trials (RCTs) have been published on ACT to-date (ACBS, 2018). ACT THE BENEFITS OF FLEXIBILITY 4 protocols have been developed and tested for a wide range of problems within and outside mental health including depression, anxiety, obsessive compulsive-related disorders, psychosis, eating disorders, addictions, aggression, chronic pain, coping with medical conditions, obesity, and stigma as well as positive functioning in settings such as business, healthcare, athletics, and education (Hooper & Larsson, 2015). ACT has been successfully disseminated internationally, with large and growing programs of research, training, and practice in a variety of regions including Western Europe, Asia, Australia, and Iran, among others. The success of ACT can be attributed to its behavior analytic roots and the more specific scientific strategy articulated in contextual behavioral science (CBS) that guided its development (Hayes, Barnes-Holmes & Wilson, 2012; Vilardaga et al., 2009). A core feature of CBS that we will focus on in this commentary is flexibility defined in relation to theory, methodology, and intervention protocols, all of which are made coherent through an explicated philosophy and scientific strategy. This flexibility is a direct result of the unique needs and challenges that ACT developers had to address in taking a clinical behavior analytic approach to the complex behaviors typically occurring in therapy (Zettle, 2005). In the 1970s and 80s, clinical psychology was moving away from behavioral approaches, embracing cognitive theories and treatments that seemed to more adequately address complex verbal behavior (e.g., thoughts) and its interaction with psychopathology and therapeutic change. During this time, clinical psychology also became intensely focused on developing an evidence base through RCTs of treatment protocols for specific disorders. Thus, ACT developers were faced with challenges in maintaining a behavior 1 “Flexibility” is used in its more typical, colloquial meaning in this manuscript, particularly with regards to being sensitive and adaptive to target audience and contexts, rather than it’s more specific use in ACT as a shorthand for psychological flexibility. THE BENEFITS OF FLEXIBILITY 5 analytic approach that could address current needs, including a more comprehensive account of verbal behavior relevant to complex behaviors encountered in therapy, a way to bridge behavior analytic methods with the increasing emphasis on RCTs, and strategies to increase clinicians’ use of behavioral methods in a field increasingly turning to other theoretical approaches. Addressing these challenges led to articulating CBS as a scientific strategy deeply linked to behavior analysis, which provided the necessary flexibility to address the needs of clinical psychology and other applied behavioral health domains as they continued to evolve. Functional contextualism as the foundation for CBS and ACT A defining feature of CBS is its well-specified philosophy of science, functional contextualism (Hayes et al., 2012; Hayes, Hayes & Reese, 1988), which provides the foundation for the broader scientific strategy. Explicating a philosophy of science is critical for ensuring that one’s approach to theory, methodology, and practice are coherently linked to a world view and scientific goals (Vilardaga et al., 2009). This is what has allowed ACT developers to be flexible in their scientific strategy, while avoiding incoherence, ecclecticism, or an otherwise nonprogressive approach to knowledge development. Functional contextualism can be understood by its pragmatic approach to truth, in which the accuracy of a scientific analysis is defined by successful working with regard to the prediction and influence of behavior (i.e., “what works”), and its unit of analysis, the whole organism interacting with the environmental context (Hayes et al., 1988). This is aligned with and indeed derives from behavior analysis in emphasizing traditionally held assumptions, such as the importance of studying the behavior in context, looking to environmental factors to identify manipulable independent variables, and focusing on control/influence of relevant behavior, not simply prediction (Hayes et al., 1988). THE BENEFITS OF FLEXIBILITY 6 The pragmatic truth criterion serves as an organizing principle, thereby allowing for a more flexible approach to knowledge development in which any scientific methods may be used, provided they enhance prediction and influence of behavior (Vilardaga et al., 2009). In this way functional contextualism provides a guiding framework that has allowed for a more flexible approach to ACT’s development, research, and dissemination, while maintaining rigor, coherence, and progressivity. The remainder of this commentary will review examples of flexibility with ACT that derive from a CBS approach and its underlying philosophy, and which we believe have enhanced its success in dissemination and implementation. Flexibility with theory through the use of middle level terms ACT is defined by its focus on function and processes, rather than topography or procedures. This fits well with the broad scope afforded by behavioral principles, yet leaves a practical gap between highly abstracted principles and the specific contexts in which they apply. Consequently, CBS utilizes middle level terms in an attempt to help bridge these abstracted principles with the treatment contexts and domains to which they might apply. For example, negative reinforcement is a precise and broadly applicable behavioral principle, which in the domain of clinical psychology could account for a variety of pathological behaviors that function to alleviate contact with aversive internal stimuli. However, the concept of negative reinforcement alone does not necessarily point therapists to the specific, complex, and potentially subtle contingencies that are maintaining the pathological behavior patterns that present in the therapeutic context. By contrast, experiential avoidance is a middle level term in ACT that refers more specifically to rigid patterns of behavior in which individuals attempt to avoid, escape, or otherwise control the occurrence of internal states (e.g., thoughts, feelings, sensations, urges), despite undesirable consequences for doing so. THE BENEFITS OF FLEXIBILITY 7 Experiential avoidance not only refers to a more specific instance of negative reinforcement, albeit with less precise terminology, it also orients to particular features relevant to an ACT approach. For example, the rigidity of this behavioral pattern, despite its harmful consequences, orients to instances of negatively reinforced behavior in which avoidance/escape from aversive internal states is highly valued relative to other consequences that might otherwise reduce the probability of avoidance/escape (e.g., lost opportunities for positive reinforcement, additional aversive consequences due to avoidance behavior). Additionally, the emphasis on “attempts to avoid” highlights that experiential avoidance may occur in contexts in which an individual lacks a history of direct negative reinforceme

The Potential Benefits of Flexibility for Dissemination and Implementation: Acceptance and Commitment Therapy as an Example