"argue that empirical clinical psychology is hampered in its efforts to alleviate human suffering and present contextual behavioral science (CBS) to address the basic philosophical, theoretical and methodological shortcomings of the field. CBS represents a host of good ideas but at times the promise of CBS is obscured by excessive promotion of Acceptance and Commitment Therapy (ACT) and Relational Frame Theory (RFT) and demotion of earlier cognitive and behavior change techniques in the absence of clear logic and empirical support." Nevertheless, Kanter concluded that "the ideas of CBS, RFT, and ACT deserve serious consideration by the mainstream community and have great potential to shape a truly progressive clinical science to guide clinical practice". A 2013 paper comparing ACT to cognitive therapy (CT) concluded that "although preliminary research on ACT is promising, we suggest that its proponents need to be appropriately humble in their claims. In particular, like CT, ACT cannot yet make strong claims that its unique and theory-driven intervention components are active ingredients in its effects." The authors of the paper suggested that many of the assumptions of ACT and CT "are pre-analytical, and cannot be directly pitted against one another in experimental tests." In 2012, ACT appeared to be about as effective as standard CBT, with some meta-analyses showing small differences in favor of ACT and others not. For example, a meta-analysis published by Francisco Ruiz in 2012 looked at 16 studies comparing ACT to standard CBT. ACT failed to separate from CBT on effect sizes for anxiety, however modest benefits were found with ACT compared to CBT for depression and quality of life. The author did find separation between ACT and CBT on the "primary outcome" – a heterogeneous class of 14 separate outcome measures that were aggregated into the effect size analysis. This analysis however is limited by the highly heterogeneous nature of the outcome variables used in the analysis, which has the tendency to increase the number needed to treat (NNT) to replicate the effect size reported. More limited measures, such as depression, anxiety and quality of life decrease the NNT, making the analysis more clinically relevant, and on these measures ACT did not outperform CBT. A 2012 clinical trial by Forman et al. found that Beckian CBT obtained better results than ACT. Several concerns, both theoretical and empirical, have arisen in response to the ascendancy of ACT. One major theoretical concern was that the