Acceptance and Commitment Therapy (ACT) is a form of cognitive-behavioral therapy (CBT) that aims to increase psychological flexibility – the ability to stay in contact with the present moment and choose behaviors in line with one’s values, even in the face of difficult thoughts and feelings.
Rather than trying to eliminate unwanted internal experiences, ACT teaches skills to lessen their impact and importance, allowing people to pursue valued life directions even when unpleasant experiences persist.
The overarching goal of ACT is not symptom reduction per se, but living a more vital, values-consistent life through acceptance, mindfulness, and behavior change.
When is ACT used?
ACT is a transdiagnostic approach, meaning it can be applied to a wide range of psychological problems rather than a single disorder.
Randomized controlled trials support the efficacy of ACT for a variety of conditions, including:
- Anxiety disorders
- Depression
- Substance use
- Chronic pain
- Psychosis
- Obsessive-compulsive disorder
- Eating disorders
- Behavioral health concerns like smoking, diabetes management, and weight control
ACT may be especially well-suited for chronic conditions involving experiential avoidance – persistent attempts to avoid unwanted thoughts and feelings that paradoxically increase their frequency and impact.
How ACT works
ACT relies on six core processes to build psychological flexibility:
Acceptance
Rather than fighting unwanted feelings, acceptance involves making space for them, allowing them to come and go without struggle.
Therapists help clients practice acceptance through exposure exercises and metaphors that encourage adopting an open, receptive stance toward internal experiences, even if they are unpleasant.
The goal is to contain difficult feelings lightly, like holding a delicate flower, rather than crushing them with avoidance attempts.
For example: A client with panic disorder may practice acceptance by intentionally bringing on mild sensations of dizziness or breathlessness, observing them with curiosity rather than trying to control or eliminate them.
Cognitive Defusion
Cognitive defusion techniques aim to reduce the impact of unhelpful thoughts by changing one’s relationship to the thought rather than the thought itself.
Through defusion, clients learn to view thoughts as transient mental events rather than literal truths that dictate behavior.
Defusion exercises include labeling thoughts as thoughts (e.g., “I’m having the thought that I’m unlovable”), speaking thoughts in silly voices, or rapidly repeating a word until it loses meaning.
For example: A client struggling with self-critical thoughts may practice defusion by singing their thoughts to the tune of “Happy Birthday,” creating distance from their literal meaning.
Being Present
ACT teaches mindfulness skills to help clients contact the present moment rather than dwelling on the past or worrying about the future.
Exercises such as noticing the breath, observing sounds, or scanning the body cultivate flexible attention to current experience.
Therapists also help clients attend to the present during sessions, tracking subtle emotional and behavioral responses as they occur.
For example: During a session, the therapist may invite the client to pause and notice five things they can see, four things they can touch, three things they can hear, two things they can smell, and one thing they can taste, grounding them in the present moment.
Self as Context
Self as context refers to contacting a transcendent sense of self that is distinct from one’s passing thoughts, feelings, and experiences.
Through metaphors and perspective-taking exercises, clients access a continuity of consciousness that has been present throughout their lives, like a boundless sky holding various weather patterns.
This flexible sense of self provides a vantage point from which to notice internal experiences with greater equanimity and choice.
For example: The therapist may guide the client through the “Observer Exercise,” inviting them to recall a difficult childhood memory, then step back and notice that the “you” observing the memory is the same “you” that is present now, untouched by the painful experience.
Values
Values work involves identifying chosen life directions – deeply meaningful qualities of action that can guide behavior.
Therapists help clients clarify values through reflection, assessment, and experiential exercises, while undermining rigid rules that restrict vitality.
Meaningful moments invariably reflect valued actions, while painful experiences contain opportunities to recommit to values like love and growth. Values are held lightly yet earnestly, as welcome companions on the ongoing journey of life.
For example: The therapist may invite the client to write a eulogy for their 80th birthday, reflecting on what they would want their loved ones to say about the qualities they embodied and the impact they had on others’ lives.
Committed Action
Committed action entails setting goals guided by one’s values and taking concrete steps to achieve them.
Behavior change strategies from across therapies can be applied, such as exposure, skill acquisition, or habit reversal.
The key is that change efforts are linked to chosen values and grounded in acceptance and defusion. Barriers invariably arise, but psychological flexibility allows recommitting to valued action again and again.
For example: A client who values environmental stewardship may commit to specific actions like biking to work, volunteering for beach cleanups, and reducing their plastic consumption, even when inconvenient or uncomfortable.
How effective is ACT?
Numerous studies have investigated the effectiveness of Acceptance and Commitment Therapy (ACT) for a wide range of mental health conditions.
A meta-analysis found ACT to be effective in reducing symptoms of anxiety and depression when compared to a placebo.
A more recent meta-analysis of 18 RCTs specifically examining ACT for depression found that ACT significantly reduced depressive symptoms compared to control groups, with the most substantial improvements observed at a three-month follow-up.
Another meta-analysis reviewed 20 meta-analyses, encompassing 133 studies and 12,477 participants, and concluded that ACT is efficacious for anxiety, depression, addiction, pain, and transdiagnostic groups, outperforming inactive control conditions and treatment as usual.
Importantly, these meta-analyses also found that the effectiveness of ACT was maintained over time, with benefits often persisting at follow-up assessments several months after treatment. This suggests that ACT may lead to lasting improvements in mental health.
While further research is needed to establish ACT’s efficacy relative to other treatments, the current evidence suggests that ACT is a promising therapeutic approach that may lead to significant and lasting improvements in psychological wellbeing.
Possible limitations
While ACT has demonstrated efficacy for a range of concerns, it may not be the optimal fit for every individual or situation.
The open, experiential nature of ACT can initially feel challenging for clients accustomed to more structured, didactic therapies (Hayes et al., 2011).
ACT’s emphasis on accepting discomfort and pursuing valued actions despite unpleasant internal experiences may not resonate with clients seeking quick symptom relief or believing that happiness depends on eliminating suffering (Lee et al., 2021).
Additionally, ACT’s focus on personal values and individual choice may require extra sensitivity and adaptation in certain cultural contexts that prioritize social harmony or interdependence over autonomy (Hayes & Lillis, 2012).
Finally, while ACT is transdiagnostic, clients with active psychosis, severe depression, or cognitively demanding conditions may need a slower pace, concrete adaptations, and close coordination with their medical providers to ensure safety and engagement (Hayes et al., 2011).
What to Expect in ACT
Below are things to expect if considering ACT:
- Sessions often incorporate mindfulness practices, experiential exercises, metaphors, and role-plays to foster present-moment awareness and illustrate ACT processes
- Therapists take a non-judgmental, compassionate stance while encouraging clients to practice new ways of relating to internal experiences in service of their values
- Between-session practice is critical for applying acceptance, defusion, and values-based action skills to real-world challenges
- Clients may temporarily experience increased distress as they confront previously avoided thoughts, feelings, and situations
- Over time, clients often report increased vitality, self-compassion, and ability to handle life’s difficulties
- ACT aims to help clients build meaningful lives by embracing both the joys and sorrows of the human experience
ACT vs CBT
While ACT and traditional CBT share behavioral roots, they differ in important ways. Both approaches target cognition, but CBT seeks to modify irrational thought content, whereas ACT aims to alter the context and function of cognition (i.e., whether thoughts are believed and acted upon).
Additionally, CBT focuses more on symptom reduction, while ACT emphasizes pursuing a meaningful life in the face of symptoms.
Still, both therapies recognize the importance of the therapeutic relationship, behavioral rehearsal, and aligning treatment with the client’s goals.
Some studies have found ACT to be equally effective to CBT, while others suggest ACT may lead to greater improvements in certain areas, such as quality of life.
However, more research directly comparing ACT and CBT is needed to clarify their relative efficacy.
Many contemporary CBT approaches also incorporate elements of acceptance and mindfulness, reflecting the influence of contextual approaches like ACT, while ACT protocols for specific disorders often include traditional behavioral components.
Ultimately, the approaches can be seen as complementary, with different means to the shared end of reducing suffering and improving clients’ lives.
References
A-Tjak, J. G. L., Davis, M. L., Morina, N., Powers, M. B., Smits, J. A. J., & Emmelkamp, P. M. G. (2015). A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems. Psychotherapy and Psychosomatics, 84(1), 30-36. https://doi.org/10.1159/000365764
Bai, Z., Luo, S., Zhang, L., Wu, S., & Chi, I. (2020). Acceptance and Commitment Therapy (ACT) to reduce depression: A systematic review and meta-analysis. Journal of affective disorders, 260, 728-737. https://doi.org/10.1016/j.jad.2019.09.040
Gloster, A. T., Walder, N., Levin, M. E., Twohig, M. P., & Karekla, M. (2020). The empirical status of acceptance and commitment therapy: A review of meta-analyses. Journal of contextual behavioral science, 18, 181-192. https://doi.org/10.1016/j.jcbs.2020.09.009
Hayes, S. C., & Lillis, J. (2012). Acceptance and commitment therapy. American Psychological Association.
Hayes, S. C., Levin, M. E., Plumb-Vilardaga, J., Villatte, J. L., & Pistorello, J. (2013). Acceptance and commitment therapy and contextual behavioral science: Examining the progress of a distinctive model of behavioral and cognitive therapy. Behavior Therapy, 44(2), 180–198. https://doi.org/10.1016/j.beth.2009.08.002
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), 1-25. https://doi.org/10.1016/j.brat.2005.06.006
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and commitment therapy: The process and practice of mindful change. Guilford Press.
Lee, E. B., Pierce, B. G., Twohig, M. P., & Levin, M. E. (2021). Acceptance and commitment therapy. In A. Wenzel (Ed.), Handbook of cognitive behavioral therapy: Overview and approaches (pp. 567–594). American Psychological Association. https://doi.org/10.1037/0000218-019
Levin, M. E., & Hayes, S. C. (2009). Is acceptance and commitment therapy superior to established treatment comparisons? Psychotherapy and Psychosomatics, 78(6), 380-381. https://doi.org/10.1159/000235978
Levin, M. E., Hildebrandt, M. J., Lillis, J., & Hayes, S. C. (2012). The impact of treatment components suggested by the psychological flexibility model: A meta-analysis of laboratory-based component studies. Behavior Therapy, 43(4), 741-756. https://doi.org/10.1016/j.beth.2012.05.003
Powers, M. B., Vörding, M. B. Z. V. S., & Emmelkamp, P. M. G. (2009). Acceptance and commitment therapy: A meta-analytic review. Psychotherapy and Psychosomatics, 78(2), 73-80. https://doi.org/10.1159/000190790
Ruiz, F. J. (2012). Acceptance and commitment therapy versus traditional cognitive behavioral therapy: A systematic review and meta-analysis of current empirical evidence. International Journal of Psychology & Psychological Therapy, 12(3), 333-357. https://www.ijpsy.com/volumen12/num3/334.html
