Acceptance and Commitment Therapy (ACT): What It Is & How It Works

What Is ACT Therapy?

Acceptance and Commitment Therapy operates from the lens that pain and suffering are inevitable parts of life. Instead of trying to control or avoid pain and suffering, ACT therapists encourage people to accept and make room for these experiences.

The ultimate goal of ACT therapy is not to be happier, but to develop “psychological flexibility” and to live a full and meaningful life. Psychological flexibility is defined as a state of openness that allows people to be fully present in their experiences (even when these experiences are painful or upsetting) and to make choices based on their personal values.

Acceptance and commitment therapy can be summarized using the acronym ACT, which can also stand for:

• Accept thoughts and feelings and be present
• Choose a valued direction
• Take action

How Does Acceptance and Commitment Therapy Work?

There are six core processes in ACT therapy that help clients develop psychological flexibility:

1. Contact With the Present Moment

Mindfulness is the practice of being fully aware and engaged in the present in a nonjudgmental way. Mindfulness can be used to fully engage with a person’s external circumstances like where they are and what they are doing, or to get in touch with inner thoughts and feelings. Mindfulness in ACT is encouraged even when inner or outer experiences are painful or difficult.

2. Cognitive Defusion

Cognitive defusion is the practice of distancing oneself from one’s thoughts. Cognitive defusion is also accomplished through the use of mindfulness skills. These skills teach people to observe their thoughts in a detached way, as opposed to getting involved in them.

3. Acceptance

Acceptance of difficult thoughts and feelings is another core component of ACT. While the general instinctive response to psychological pain is to try to stop it or avoid it, ACT encourages people to instead open up and invite those feelings in. In doing so, people tend to experience that these thoughts and feelings are only temporary, and dissipate on their own.

4. Self as Context

ACT therapists believe that most people get too wrapped up and involved in their own thoughts. Most thoughts come in first-person “I” language and ACT believes this language keeps people stuck and fused in unhelpful thoughts. Instead, ACT encourages people to use an “observing” part of their mind to notice the thoughts that come and go. For instance, a person might describe, “I’m noticing thoughts about not being good enough” instead of, “I’m not good enough.”

5. Personal Values

Personal values are another central concept in ACT. Highly individualized, personal values are principles and activities that give meaning and purpose to a person’s life. ACT therapists believe that people are most satisfied when they are acting according to their values. Part of ACT therapy is usually for a person to identify their core values and assess the degree to which they are demonstrating each value in their day to day lives.

6. Committed Action

Committed action describes following through with acting in accordance with one’s personal values. This might sometimes mean that a person has to open themselves up to the possibility of being hurt, scared, or disappointed as they work to build a life that is meaningful.

Mindfulness & ACT Therapy

An attractive feature of ACT is that it works to incorporate other mental health resources into its use. ACT and mindfulness work well together, since increasing mindfulness will actually enhance the practice of ACT principles. In combination, using ACT with mindfulness can produce powerful results.

What Can ACT Therapy Help With?

Acceptance and Commitment therapy is used to treat a variety of mental health and substance use disorders, as well other non-clinical issues that sometimes bring people into counseling (like stress, grief, commitment issues, or improving work/life balance). ACT is a relatively new type of therapy that utilizes some of the same techniques used in experiential therapy. Research is ongoing to identify which conditions it can effectively treat.

ACT for Mental Health Disorders

Currently, there is evidence to support that ACT is effective in treating the following disorders:^2,3

• Depression
• Anxiety
• Chronic pain
• Obsessive compulsive disorder
• Psychosis
• Substance use disorders

ACT for Other Life Stressors

While there is not clear evidence to support the use of ACT for each issue listed below, many ACT therapists describe success in using the treatment for other issues as well.

These include:

• Grief or bereavement
• Divorce or separation
• Burn-out or work/life imbalance
• Interpersonal conflicts
• Chronic illness
• Parenting difficulty

What Are the Benefits of ACT?

ACT is a helpful therapeutic tool when used alone or in combination with other proven mental health interventions. Of course, all people will not experience ACT in the same way, but many will be able to experience its positive outcomes.

Some common benefits of ACT include:

• Improving symptoms of mental health issues like depression and anxiety
• Changing the way a person relates to their unwanted thoughts
• Changing their experience of emotions
• Allowing the person to separate from their thoughts
• Increasing presence in one’s surroundings
• Being able to commit to the important qualities of life

ACT Therapy Techniques

Counselors who use Acceptance and Commitment Therapy have an array of techniques and strategies they use to help clients. Early on in treatment, ACT therapists may focus on providing education to help clients better understand ACT theory. ACT therapists then help clients evaluate their current ways of coping with and responding to difficult thoughts and feelings.

Often, this evaluation reveals that the client has been using ineffective, or even counterproductive, methods of coping. In these cases, ACT therapists teach clients more effective ways to respond to difficult thoughts and feelings. Finally, ACT therapists help clients identify their core values and make changes to their behavior that result in more consistent demonstration of their values.

Metaphors to Teach ACT Theory

Early in treatment, ACT therapists use metaphors to teach clients new ways of understanding their emotions and how to best respond to them.

Common ACT metaphors include:

Drivers Vs. Passengers

ACT therapists help clients understand that difficult emotions can either be drivers or passengers. When difficult emotions like anger or fear are permitted to drive, they often become destructive forces that cause problems in a person’s life and keep them from getting where they need and want to go. ACT therapists encourage clients to get and stay in the driver’s seat and to have difficult emotions be the passengers. While they may be unpleasant passengers, not allowing them to drive is key to reducing the impact they can have on a person’s life and choices.

Beach Ball Underwater

ACT therapists teach clients that efforts to stop or control difficult thoughts and feelings can be exhausting and ineffective. To illustrate this, they sometimes use the metaphor of emotional control being like trying to push a beach ball underwater; it takes a lot of effort and energy and ultimately isn’t effective. While it might provide temporary relief, the difficult thoughts and feelings tend to “pop back up” later on.

Quicksand

Another metaphor ACT therapists use to help clients understand the ways that trying to resist or control emotions is ineffective is a metaphor of quicksand. When people stuck in quicksand try to struggle free, they ultimately end up getting more stuck. Instead, working to relax, breathe, and move slowly and deliberately is the way to get free from quicksand, and also the way to get unstuck from difficult thoughts and feelings.

Experiential Techniques to Teach ACT Theory

Therapists who provide ACT treatment also utilize experiential techniques that help to demonstrate key concepts of the theory. When a client becomes upset, angry, or anxious in session, the therapist may welcome this as an opportunity to practice mindfulness and acceptance.

The therapist might encourage the client to sit with the feeling, try to open up around it and give it space. The therapist might get the client to become curious about the emotion by asking questions about specific sensations or descriptions of the emotion they are experiencing.

Other experiential techniques an ACT therapist might utilize are those designed to illustrate the counterproductive nature of control or avoidance strategies.

Evaluating Control & Avoidance Strategies

ACT posits that most of the time, psychological suffering is caused or made worse by control and avoidance strategies. Control and avoidance strategies include anything a person does to attempt to change, stop, fix, or avoid difficult thoughts and feelings.

Some common control and avoidance strategies include:

• Distraction: Distraction techniques are any activity or mental task that people engage in to temporarily distract themselves from specific unwanted thoughts and feelings. These might include watching TV, going online, or even just staying constantly busy with tasks at work or at home.
• Opting Out: Opting out includes all of the ways that people may avoid, quit, or withdraw from situations that might result in unwanted thoughts and feelings. Opting out could include canceling plans with friends, backing out of a project at work, or avoiding doing new things because of a fear of failure or rejection.
• Overthinking: Overthinking or overanalyzing is another common way that people try to control unwanted thoughts and feelings. Overthinking includes obsessively reviewing the problem, finding blame, trying to problem solve or predict outcomes, self-criticizing, or any other mental task aimed at stopping or fixing a feeling or thought.
• Substance misuse or self-harm: Some people engage in self-destructive behaviors like self-harm (i.e. cutting), substance use, or other risky behaviors. These behaviors can be both a way of expressing pain and a way of coping with pain.

Teaching Acceptance, Mindfulness, and Defusion Skills

Usually, evaluating current methods of control and avoidance leads to an agreement that these tactics have only been partially effective or in some cases, may have been ineffective or even made things worse. While ACT therapists encourage the client to not use control and avoidance strategies, they also recognize the need for more effective ways to cope and respond to difficult thoughts and feelings.

Some of the skills that ACT therapists teach include:

Acceptance Skills

Acceptance of difficult thoughts, feelings and experiences is central to Acceptance and Commitment Therapy. Clients are taught to expand, or open up, around difficult and painful experiences, rather than to try to stop or control them. Acceptance does not mean that a person likes or wants the difficult thoughts and feelings, only that they are willing to tolerate them and not waste time and energy trying to control them.

Mindfulness Skills

Mindfulness is the practice of being fully present, open, aware, and engaged in the here and now. Mindfulness can be used to focus on a narrow aspect of one’s current experience (like on one’s breathing) or to expand to a broader field of awareness (like what a person can see, hear, feel, and smell). Using mindfulness, people practice being present in whatever their current experience is.

Defusion Skills

Defusion (also called cognitive defusion) is a skill that helps people distance themselves from their thoughts. Defusion helps people understand that they are separate from difficult thoughts and feelings and encourages people to become observers of these thoughts, almost like they are watching words and images on a screen. Defusion does not mean getting rid of or changing thoughts, it just means recognizing that those thoughts are not always true or important.

Identifying Values & Committing to Action

A central part of ACT treatment involves identifying values and encouraging clients to act in ways that align with these values. Values represent what matters most to people: the activities that bring them joy, the principles they stand for, the impact they want to make on the world, and the things that make life full and meaningful. Usually, a client will work to come up with an initial list of values and then pare this list down to a smaller, final list of core values.

Using these core values, a therapist will then help the client evaluate the extent to which their actions demonstrate each of these core values. ACT therapists believe that acting in accordance with values, instead of in reaction to emotions, is the key to a full and meaningful life. Clients will be encouraged to identify ways that they can change their behavior to be more aligned with their core values.

How Is an ACT Therapy Session Structured?

Like other forms of therapy, ACT sessions may all appear unique and individualized. Despite their differences, though, there will be some common structure to many sessions, including:

• Building rapport: Having a strong relationship between client and therapist almost always improves outcomes. Rapport may be built by getting to know each other, sharing information, or by viewing the therapist as a competent professional.
• Developing deeper awareness: ACT cannot move forward without having an awareness of one’s thoughts, experiences, and feelings. Attending to these aspects will help the treatment to progress.
• Determining core values: What is important to the client and what motivates their need for change? By determining these core values, treatment has direction and drive.
• Committing to specific actions: In the end, treatment aims to change behaviors, so setting specific goals will be on the agenda. The following session can focus on reviewing the goals to identify barriers or reasons for success.

ACT Examples

Clients of ACT therapists might be initially surprised that the focus of treatment is not centered around reducing their symptoms. While other treatment approaches see difficult thoughts and feelings as indicators of mental illness, ACT therapists are more likely to see these inner experiences as a normal part of life. In ACT, the focus is typically on a client’s response to these inner experiences, rather than on the inner experiences themselves.

For example, a client who is coming to therapy for depression might cite symptoms like sadness, fatigue, and a lack of interest and motivation as the problems they want to solve in therapy. An ACT therapist is more likely to dig deeper to find out what the client does when these symptoms arise. Do they stay in bed, isolate themselves, cancel plans? Do they ruminate on sad things that have happened in the past or on negative thoughts about the future? If so, these responses would be targeted as a focus of treatment.

An ACT therapist would spend time helping the client explore how these behaviors have affected their experience of symptoms and their overall quality of life. They would encourage the client to try out different responses to these symptoms. Instead of ruminating on negative and sad thoughts, the client might be encouraged to use defusion or mindfulness to observe these thoughts from a distance. Instead of staying in bed, isolating themselves, and canceling plans, the therapist might work to understand what activities and relationships are important and meaningful to the client, and to encourage them to engage in these even when they experience symptoms.

Throughout the course of ACT therapy, a client learns new ways of thinking about, experiencing, and responding to difficult thoughts and feelings. ACT therapists emphasize that living lives that are full and meaningful also means being willing to accept and experience difficult and painful thoughts and feelings.

ACT teaches people skills to manage these inner experiences without letting them restrict their ability to function or enjoy life. While the expressed goal of ACT therapy is not to reduce the client’s symptoms of depression, symptom reduction is usually a byproduct of the treatment.

How to Find an ACT Therapist

ACT is typically provided by licensed professional counselors, social workers, or psychologists. Usually, ACT therapy occurs in weekly outpatient sessions lasting about an hour. ACT treatment typically lasts between 8-16 weeks, although this can vary, depending on the individual needs and goals of each client.

Finding a therapist who specializes in acceptance and commitment therapy is easier than ever before, thanks to the internet. A good starting place is an online directory to help locate therapists near you. It is usually possible to narrow down the search to providers who are trained in ACT, and also those who specialize in specific issues like depression, anxiety, or addiction.

Many people are also interested in finding a therapist who is in-network with their insurance. Contacting your insurance company is also a good way to find an in-network therapist. Usually, the best way to begin this process is to either call the number on the back of the insurance card or to use the insurance company’s website to conduct a search for in-network counselors.

What to Look for in an Acceptance and Commitment Therapist

Good ACT therapists will be ones who have the experience and education specific to the therapeutic model. There is a big difference between a therapist who says they use ACT and one with the proper training.

When seeking ACT, you should look for:

• Graduate-level education from a program focused on ACT
• On-going professional supervision or consultation from an ACT expert
• Trainings to illustrate continuing education on the newest advancements in ACT

The Association for Contextual Behavioral Science, the international ACT group, does not offer an official certification in ACT at this time. Other groups may offer certificates and training programs, though.

What to Expect at Your First ACT Appointment

The first appointment with a therapist is generally reserved for a diagnostic assessment and intake. This appointment typically lasts 60-90 minutes and involves a counselor getting background information about you and the issues you wish to address. A lot of questions are asked during this appointment and the information collected is important in helping the counselor determine a diagnosis, which is normally discussed at the end of the appointment. You will also be asked to fill out paperwork which involves standard consent forms and other administrative paperwork needed to establish care.

Towards the end of the first appointment, the counselor will discuss your diagnosis and options for treatment. Treatment recommendations will be made by the counselor based on their assessment, but your input is also essential in determining next steps. If you have questions about your treatment, this is also the time to ask them. If you and the counselor decide to meet for future sessions, these will probably be different than the first appointment. Sometimes, medication is also recommended in conjunction with therapy.

While the first appointment is focused on getting the needed information and forms, establishing a diagnosis, and making a treatment recommendation, subsequent sessions tend to be more focused on the issues bringing you in and the goals you have for treatment. ACT can be helpful for people without a formal mental health diagnosis, but generally a diagnosis is required for those wanting to have sessions covered by their insurer.

Is ACT Therapy Effective?

Acceptance and Commitment Therapy is gaining recognition as an Evidence Based Practice. It is listed as an Evidence Based Practice on SAMHSA’s national registry and as a research-supported treatment by the APA. ACT has the most research backing its efficacy in treating depression, psychosis, anxiety, OCD and chronic pain.⁴

There is emerging evidence to suggest that ACT could also be effective in treating substance use disorders and PTSD, although more research is needed in these areas.^5,6 As a relatively new treatment, ACT is still being studied to better understand its applications.

How Is ACT Different From CBT or DBT?

All belonging to the family of behavior therapies, ACT, Cognitive Behavioral Therapy (CBT) and Dialectical Behavioral Therapy (DBT) all share a common foundation of focusing on behavior change. Out of the three treatments, CBT is most different. In CBT, difficult emotions are thought to be caused or closely linked to specific unhelpful thought patterns.

CBT therapists encourage clients to reframe or rethink their thoughts in more helpful ways that lead to improvements in their emotional state and behavior. ACT therapists believe that putting effort into rethinking or changing thoughts is unhelpful and sometimes can lead to becoming more stuck.

Instead, ACT and DBT recognize thoughts as playing a role in emotional distress but instead of changing them, both approaches encourage the use of mindfulness to get distance from them. In both approaches, clients are also encouraged to be willing to accept and experience difficult emotions. The skills in both ACT and DBT are packaged differently but ultimately are variations of mindfulness skills. The behavioral focus paired with the focus on mindfulness is what connects both ACT and DBT, placing them in the same category of “third wave” behavior theories.

One aspect of ACT that is unique is the focus on personal values. In ACT, clients are encouraged to identify their personal values and use these as a compass to guide more effective actions and behaviors. The central focus on personal values is not found in other therapies in the third wave behavior family (like DBT, Metacognitive Therapy, or Mindfulness Based Cognitive Therapy).

History of ACT Therapy

Acceptance and Commitment Therapy was developed in 1986 and is credited to the work of psychologist, professor, and author Dr. Stephen Hayes. Its roots lie in several existing theories including an earlier theory developed by Hayes called Relational Frame Theory. Other theories that have influenced ACT include 1st and 2nd wave behavior theories, Existentialism, and Humanistic approaches.

At the time ACT was developed, CBT was the leading treatment of choice. In many ways, ACT emerged as a challenge to certain fundamental assumptions of the CBT model, including the idea that thoughts and feelings are symptoms and that they can be controlled. Hayes forwarded the idea that difficult thoughts and feelings are normal but that many of the techniques people use to try to control or avoid them lead to more suffering. Many of these techniques were touted by CBT therapists as skills to reduce unwanted symptoms.