ACT for Anxiety: How It Works, Examples, & Effectiveness

What Is Acceptance & Commitment Therapy?

Acceptance and commitment therapy (ACT)  is a type of cognitive behavioral therapy that aims to reduce psychological distress by focusing on accepting thoughts and feelings without judgment and taking action based on values rather than on fears or anxious thoughts. ACT uses tools such as mindfulness and creative helplessness to help individuals cope with conditions like depression, anxiety, and trauma.

The acronym ACT stands for:

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

ACT therapy uses six key processes: contacting the present moment, defusion, acceptance, self-as-context, values, and taking committed action. These processes work together to help a person notice and accept their anxious thoughts and feelings, reduce the control anxiety has over their lives, understand that their anxiety is not who they are, and live their life based on what is most important to them rather than on fearful thoughts and emotions.

How Does ACT Help With Anxiety Symptoms?

ACT helps people be more mentally flexible and not so attached to their thoughts. It helps people to disconnect from their anxious thoughts by understanding that those thoughts are not the absolute truth. It also teaches skills around tolerating anxiety without judging oneself. It also encourages people to identify and take action based on their values rather than based on fears.¹

Here is how ACT can help with the different types of anxiety disorders:

ACT for Generalized Anxiety Disorders

Generalized anxiety disorder (GAD) is a common mental disorder characterized by a persistent worry about multiple things for more days than not for at least six months. This is beyond normal worried thoughts, but excessive worry that impacts a person’s ability to function in everyday life. ACT encourages individuals with GAD to clarify their values and commit to actions aligned with those values rather than allowing anxiety to control their lives. Additionally, ACT mindfulness techniques can help reduce rumination and catastrophizing.

ACT for Panic Disorders

Panic disorder includes panic attacks, which are episodes of intense fear and anxiety that include physical symptoms. People with this disorder often fear future panic attacks and avoid people or situations that may trigger them.  ACT helps individuals with panic disorder by assisting them to accept bodily sensations associated with panic attacks. It also teaches them to defuse their identity from catastrophic thoughts about the fear of future panic attacks.

ACT for Social Anxiety Disorders

Social anxiety disorder is characterized by an intense fear of people or social situations. Fears often center around being embarrassed, left out, humiliated, or not being able to connect with others. People with this disorder will often avoid social situations or tolerate them with extreme distress. ACT helps individuals with social anxiety to identify their values around social connections, which can help them to push past the anxiety and gradually commit to engaging socially. Experiential exercises in ACT are especially beneficial for desensitizing individuals to their fears in social situations.

ACT for Specific Phobias

Specific phobias are fears of specific things, such as heights, spiders, or leaving the house (agoraphobia). A person with a phobia will experience extreme distress, fear, and avoidance when faced with the feared object or situation. ACT helps individuals with specific phobias to defuse their identity from catastrophic thoughts about the feared object or situation.

Does ACT Effectively Treat Anxiety?

ACT has been shown to be an effective treatment for anxiety in many controlled studies, helping people to experience less distress day-to-day. Mental health studies often compare the treatment they are studying with a placebo (no treatment) or treatment as usual, which is whatever they were doing before. ACT has been shown to be better than placebo and equally effective as treatment as usual.²

While ACT is a good treatment for anxiety, it’s not necessarily better than other types of therapy. It’s more a matter of finding a good fit for each person. ACT works on accepting and tolerating anxious thoughts and feelings rather than directly trying to change them. It would be a good fit for someone whose goal is to stop battling with their thoughts and start living a good life in spite of anxiety.

ACT Vs. CBT

One of the primary differences between ACT and cognitive behavioral therapy (CBT) to treat anxiety is the focus on thoughts. CBT examines the relationship between thoughts and emotions and seeks to change irrational or unhelpful thoughts. ACT, on the other hand, does not directly try to change thoughts but rather helps a person disconnect from them and take committed action.

Both CBT and ACT have been shown to be effective, and with ACT being an offshoot of CBT, they share many similarities. Studies show that, overall, both are very effective treatments for anxiety and have similar success rates. One is not significantly more effective than the other, so when an individual is deciding between the two, it is a matter of preference and availability.³

ACT Vs. Exposure Therapy

Both ACT and exposure therapy for anxiety are shown to be effective treatments for anxiety but are based on different principles.  Exposure Therapy exposes individuals to anxiety triggers in a controlled manner, which slowly reduces their fear responses. Exposure therapy is particularly effective for specific phobias. In contrast, ACT focuses on accepting the presence of anxiety and may work better for someone with general anxiety or a lot of worried thoughts.⁴

ACT Vs. DBT

ACT and dialectical behavior therapy (DBT) for anxiety share many commonalities and are both effective treatments for anxiety disorders. DBT’s emotional regulation module would be especially beneficial for someone whose anxiety causes emotional dysregulation. Similarly, DBT’s distress tolerance module would be helpful for individuals with panic disorder. On the other hand, ACT may work better for someone with general anxiety who is working on accepting their anxiety.⁵

ACT Therapy Techniques Applied to Anxiety

ACT is based on acceptance, mindfulness, and defusion skills. Acceptance skills can help someone learn to accept their anxiety and take action anyway. Mindfulness skills support being present at the moment rather than worrying about the past or future. Defusion skills allow someone to distance themselves from their anxious thoughts, not giving them as much power.

Here is how ACT therapy techniques are applied to anxiety:

Acceptance, Mindfulness, and Defusion Skills

ACT utilizes acceptance, mindfulness, and defusion skills to help a person unhook from their anxious thoughts and take action based on their values. This is based on the belief that it is possible to experience both seemingly contradictory things at the same time; for example, feeling anxious about public speaking while still going through with giving the speech.⁶

Skills that are taught in anxiety treatment include:

• Acceptance skills: This refers to resisting the urge to avoid anxiety-inducing experiences and rather accepting that the anxiety is just there, but it doesn’t have to dictate one’s actions. This includes learning the difference between thoughts, feelings, and actions.
• Mindfulness skills: These skills allow someone to simply notice what is happening in the present moment without judgment. In the case of anxiety, a person may notice that their palms are sweaty without making up a story about what that says about them or changing their behavior as a result.
• Defusion skills: This involves understanding that thoughts are just thoughts; they are not who a person is, they are not necessarily a reality, and they don’t have to determine the outcome. Thoughts are seen as just a normal part of the human experience, and skills involve separating oneself from the thoughts so they don’t have so much power.

Identifying Values & Committing to Action

ACT therapy helps people take action based on their values rather than thoughts, fears, or whether they meet a certain goal. This allows them to enjoy the journey by noticing the beauty along the way rather than worrying about the outcome of getting to the destination. It also involves clarifying the values that are most important to them and aligning their actions with those behaviors.

For example, imagine a person who values creativity and has just started a new piece of artwork. Focusing on what they want the end result to be and the perfectionism it requires will make the process anxiety-producing and stressful. However, focusing on the creative process allows them to enjoy it more.

Evaluating Control & Avoidance Strategies

ACT makes a distinction between the discomfort of dealing with anxiety versus the discomfort caused by engaging in strategies to try to control or avoid anxiety. As hard as it can be to face difficult situations and anxiety head-on, attempts to control a situation or use avoidance behaviors to escape from the difficult feelings are often worse than the initial anxious thoughts.

For example, imagine a person having a difficult interaction at work that causes stress and anxiety. Rather than deal directly with the discomfort they are feeling, they attempt to control the situation by starting to gossip about the other person involved and going to the boss to complain about the other person.  This backfires and creates an even more stressful work environment. The person then attempts to avoid their anxiety by going out drinking and feeling terrible the next morning. The consequences of their attempts to control and avoid the situation are worse than the original discomfort.

Control and avoidance strategies that come up in anxiety treatment include:

• Distraction: Many people use distraction as a way to avoid anxiety in the present moment. This can include things like mindless scrolling on the phone, unnecessary shopping, or sex and relationships.
• Substance misuse: Drug and alcohol use may reduce anxiety temporarily, but this rarely works long-term. A person may initially use substances to reduce anxiety but later find themselves in a vicious cycle of anxiety, substance use, and worry.⁷
• Aggression: A person may dislike feeling powerless or not having control in traffic, so they act out by driving aggressively or road raging at other drivers.
• Avoidance: A person who is afraid of heights, flying, or going outside may avoid those things in order to try to control their anxiety. This can result in missing out on experiences or even staying in the house for long periods of time.

Creative Helplessness

In this technique, the therapist helps the client identify all of the things they have tried to do in order to reduce their anxiety, including getting clarity on what worked and didn’t work. After realizing the futility of previous strategies, clients are encouraged to embrace a state of “creative helplessness”, where they are inspired to seek completely new, creative, and novel solutions to their anxiety.

Self as Context

This helps clients start to view their identity as separate from their experiences. They are encouraged to adopt an observant, non-judgmental perspective that they are a person experiencing life, but they are not those experiences. For a person with anxiety, this means accepting that they are not their anxiety, rather, they are experiencing anxious thoughts and feelings that are separate from who they are.

ACT Metaphors

ACT uses metaphors to illustrate the concepts of mindfulness, committed values-based action, and thought defusion. These metaphors can help clients understand and connect with concepts that may feel complicated or abstract. Many of these metaphors have to do with ceasing the struggle and allowing anxious thoughts to just be.⁸

ACT metaphors that are used in anxiety treatment include:

• Drivers vs. passengers: In this metaphor, anxious thoughts are passengers on a bus, and the person is the driver. The driver gets to decide how fast the bus goes and where to turn. The passengers may express their anxious thoughts loudly, but the driver can disengage from them and keep driving.
• Beach ball underwater: Unwanted, anxious thoughts are like a beach ball in a pool. A person may fight to keep pushing them underwater, but they will always pop back up. However, if they allow the beach ball to float, it will eventually float away and out of their life.
• Quicksand: If a person falls into quicksand and struggles, they will sink. However, if they stop struggling and lay on top of the quicksand, they will float. The quicksand represents anxious, unwanted thoughts, and a person can simply notice them without struggling.
• Classroom: Students in a classroom all have different personalities, thoughts, and behaviors. The teacher has thoughts about the students as well as tools and strategies to teach them and get them in line. You are neither the teacher nor the students, you are the classroom.
• The sky and the weather: Weather comes, and weather goes—the clouds, rain, storms, and even beautiful sunny days all pass. The sky, however, is always there. Anxious thoughts are the weather, and you are the sky.
• Riptide: If someone has the misfortune of being caught in a riptide and they struggle, they are sure to become exhausted and drown. However, if they relax and allow themselves to be carried by the current, they will eventually come out the other side. Anxious thoughts are like a riptide, and one can simply ride them until they pass.
• Tug of war: In a game of tug of war, both sides continue pulling until they are exhausted, covered in rope burns, and one side eventually wins. In this metaphor, a person is playing tug of war with their anxious thoughts and can choose to drop the rope and walk away.

What to Expect During ACT Treatment for Anxiety

While the duration of ACT treatment will vary depending on client needs, a 12-week course of treatment is fairly typical and has been shown to be effective. ACT is a hands-on behavioral therapy, and many of the concepts are practiced in the session in real time. The therapist may also give homework to aid the client in practicing the strategies between sessions.⁹

ACT sessions will involve:

• Practicing mindfulness: The client will practice skills for being present in the current moment rather than focusing on thoughts and feelings about the past or future.
• Reviewing progress: The therapist and client will review progress since the previous week, including anxiety symptoms and the use of strategies.
• Identifying behaviors out of alignment with values: This includes identifying recent behaviors that don’t fit with the client’s identified values and noticing the effect of these behaviors on goals.
• Engaging in the six key ACT processes: A therapy session will include incorporating these processes into the session, which makes it a bit more experiential than some other types of therapy. These are contacting the present moment, defusion, acceptance, self-as-context, values, and taking committed action.
• Committing to specific actions: The client will identify and commit to small actions they can take that will get them closer to their goal.

Examples of ACT for Anxiety

ACT for Relationship Anxiety

A 30-year-old male comes to therapy because he is having relationship problems. He feels insecure and anxious about the relationship and starts an argument anytime those fears come up. He then feels guilty about his behavior and comes to therapy because he believes he  “can’t do anything right.” ACT helps him mindfully accept those anxious feelings, defuse from his thoughts, and take committed actions toward the relationship based on his values.

ACT for the Fear of Flying

A 42-year-old female has a fear of flying. She avoids flying whenever possible and has missed out on family events and vacations as a result. She has identified adventure as one of her key values, but her fear of flying blocks her from living out that value. In ACT, she learns to accept her anxious feelings, be present in the current moment, realize that her anxious thoughts are not reality, and start to take committed actions toward being able to travel.

How to Find an ACT Therapist for Anxiety

There are a few steps a person will need to take to find an ACT therapist for anxiety. You can start by asking your primary care doctor for a referral or checking online with your insurance provider for therapists who are within your network. You can also use an online therapist directory to search for therapists specializing in ACT.

Many therapists will offer a brief phone consultation, which can help you figure out if this therapist may be a good fit without spending extra money. Research shows that therapy is most effective when an individual feels safe with their therapist, so take the time to find and choose a therapist that feels right to you. In addition to traditional in-person therapy, there are now many online therapy platforms for anxiety that host therapists who specialize in ACT.

Other Treatment Options for Anxiety

While ACT is a safe and effective therapy for anxiety, other anxiety treatment options are available and may work better based on the specifics of a person’s symptoms or situation.  It is important for a person to work with their therapist to make sure that the treatment they are receiving is effective.

Other treatment options for anxiety include:

• Exposure therapy: Exposure therapy works by helping a person create a hierarchy of fears and then exposing them to those fears while practicing coping skills to reduce anxiety symptoms. This type of treatment has been shown to work especially well for phobias and OCD.
• Medications: Medications for anxiety can sometimes help, especially in combination with therapy. There are two types of medication that are prescribed for anxiety: SSRIs, a type of antidepressant, and benzodiazepines. Many providers are cautious about prescribing benzodiazepines due to the high risk of dependence, but they can be useful in certain circumstances.
• Cognitive behavioral therapy (CBT): CBT for anxiety is similar to ACT in that it focuses on anxious thoughts and behaviors. In CBT, the focus is on challenging negative or irrational thoughts and replacing them with more helpful ones.
• Eye movement desensitization and reprocessing (EMDR): EMDR for anxiety is an effective treatment when an individual’s anxiety can be traced back to a specific traumatic or upsetting event. EMDR uses bilateral stimulation to desensitize and reprocess memories, which allows the individual to work through their trauma and thereby experience a reduction in anxiety.
• Internal family systems (IFS): IFS helps clients identify the different parts of their personality that everyone has and to understand the needs and goals of each part. In IFS, anxiety would be seen as only one part and not the whole person. Once the part of the person who is experiencing anxiety is identified, the therapist works with the client to speak to that part of themselves and let that part know that they are going to take care of them.