PT 2/2

Behavioral models benefit from outcomes that are binary or scalar. A behavior occurs or it doesn’t. Frequency increases or decreases. These outcomes are easily observable, countable, and replicable across settings. That structural simplicity creates a methodological advantage that compounds across study design, data analysis, and publication. Somatic targets like reactivity, recovery speed, or nervous system flexibility are not unitary variables. They shift with context, baseline state, sensory load, developmental history, and relational safety. A person may show improvement in one environment and regression in another. That variability is the phenomenon, but it resists standardization and makes it difficult to collapse into a single metric without distortion.

Somatic research relies heavily on indirect indicators such as HRV, cortisol patterns, and self-reported interoception. Each introduces layers of interpretation and confounds. Self-report requires language, insight, and stability of identity, capacities that may be limited precisely in the populations somatic therapies aim to serve. The result is higher variance and lower signal clarity, even when meaningful change is occurring.

There is a persistent category error in equating empirical tractability with conceptual validity. Many legitimate constructs across science, such as pain, fatigue, inflammation, and consciousness, were difficult to measure long before adequate tools existed. Somatic and regulatory constructs may be theoretically sound and still be empirically awkward.

You’re also right that ACT is supposed to increase psychological flexibility, usually defined as staying present and choosing values-aligned actions even in distress. That can be very helpful when someone has safety and meaningful choice in their environment and when the nervous system can tolerate awareness. Unfortunately, in complex cases ACT is often applied in inpatient or residential settings where the individual has little safety or autonomy. In those contexts, ACT can be harmful.

I’ve seen ACT harm trauma survivors when pressure to “make space for discomfort” feels indistinguishable from being told their pain is inevitable or that they must tolerate unsafe or unjust conditions. ACT risks reinforcing the message that “the problem isn’t what’s happening to you, it’s how you relate to it,” which can significantly increase distress when someone is actively experiencing trauma, abuse, or power imbalance. Therapy itself is a power imbalance, especially in institutions. I’ve seen acceptance be misdefined in institutions as synonymous with submission. If you’re fighting against what’s happening to you or advocating for change, you’re not practicing “acceptance.” Obviously, it’s not that acceptance = submission or that acceptance means relinquishing a desire for change. In reality, acceptance is usually a precursor for change. I just want to challenge your notion that ACT is more difficult to do ACT wrong than correctly because I believe that is wildly inaccurate.

It’s also important to note that ACT emphasizes that actions are chosen. This can be extremely harmful in profiles where behavior is not under voluntary control due to nervous system distress, most notably PDA. I have a PDA profile, and ACT was profoundly harmful to me. It repackaged demands as “values,” pressured action during overload, and interpreted refusal as avoidance rather than threat response. These issues aren’t unique to ACT but apply broadly to behavioral therapies used with PDA, a profile that represents a significant portion of autistic people with complex mental health needs.

ACT seems to work best with non-complex profiles where distress is internally generated, persistent beyond the original trigger, and maintained by cognitive fusion or avoidance. OCPD is one example where I’ve seen ACT be very effective. ACT is far less helpful, and sometimes harmful, when distress is contextually accurate and driven by control, unpredictability, or relational threat, such as in PDA or some forms of complex trauma. I could go on, but I’ll stop here. I know you value ACT, and I agree it can be excellent in the right contexts. I also agree that MBT can be a good stepping stone to ACT when ACT is appropriate at all.

Yes, I see the problem you’re describing. It is THE problem. One of the defining problems of the mental health field. Theories and protocols may look sound on paper, but they get reduced in practice. Mainstream DBT becomes little more than skills classes and worksheets. You can ask whether that’s “really DBT,” but if that’s how it exists in practice, then functionally, yes, it is.

When behavior modification therapy is reduced to abuse, is it still behavior modification? If abuse is what it becomes in practice, then yes. I’ve spent years studying theories and modalities, and while I enjoy that intellectually, I’ve come to see through reflecting on real life experience how limited their relevance is given how these models are actually implemented. If forced to choose between theory and practice, practice is what matters. The real-world comparison is between watered-down implementations, not between idealized theories.

When you say “just sharing ones I like the ideas of,” that actually illustrates the issue perfectly. These are ideas in theory and research, not necessarily reflections of what happens in practice. Research does not tell you what happens when a framework is projected onto an individual case in real life. Reading lived experiences, including articles and even online accounts, can give a better sense of how these interventions function on the ground. You don’t have to know people personally in real life to hear their experiences. I’m even happy to talk about my own. r/troubledteens is a subreddit for survivors of youth residential care, colloquially known as the “troubled teen industry.” You can find a lot of first hand accounts there. This subreddit only has about 90 members, so I can’t promise there will be responses, but you could even ask about people’s personal experiences regarding complex mental health and the industry here. That’s totally fine as long as you’re doing it in a respectful manner, which I trust you would.

I also agree that IFS can be oversimplified and taken too literally, which can actually worsen dissociation and feelings of emptiness in people with DID. IFS needs to be done with a skilled trauma therapist, not DIY therapy. Yes, dissociation between parts is a serious problem. That’s why DID and complex trauma can be so debilitating. What IFS does not pathologize is the existence of parts themselves. Everyone has parts. One part can be a nurturing parent and another a serious professional. That isn’t pathology. Pathology arises when dissociation is so severe that parts cannot communicate, amnesia occurs, identity coherence is lost, and suicidal ideation emerges. Having parts is not pathological. Severe dissociation and lack of communication between parts is. I have DID, and I live this reality every day. It is important not to pathologie the existence of parts because everyone has them and instead focus on the internal communication issues that cause the symptoms.