Acceptance and commitment therapy (ACT)

Acceptance and commitment therapy, or “ACT” for short (pronounced like the word “act” rather than the abbreviation A.C.T.), is a therapy approach that people can’t help but resonate with.

ACT therapy touches on something profound in our human intuition that speaks to universal wisdom about human suffering and a pathway toward richer living. 

In fact, the founders of ACT therapy spent years developing the science-based theory (relational frame theory) and philosophy (functional contextualism) before disseminating the model, which allowed ACT to capture the human experience in powerful ways. 

Many people wonder what the difference is between ACT vs CBT. 

Acceptance and commitment therapy is a third wave therapy, as opposed to cognitive behavioral therapy (CBT), which is considered second-wave. 

Third wave behavioral therapies like ACT focus on changing one’s relationship with thoughts and feelings (i.e., altering the context in which behavior occurs) using mindfulness and acceptance-based techniques. 

CBT, on the other hand, is concerned with changing the content of thoughts and feelings through interventions like cognitive restructuring and Socratic questioning.

This article provides an overview of acceptance and commitment therapy, the six core processes of psychological flexibility, and how to use this approach in your practice.

What is ACT therapy?

Acceptance and commitment therapy acknowledges that pain is a normal part of living a full, rich, and meaningful life. For instance, creating deeply meaningful relationships requires us to show up with vulnerability to another person. Eventually, we will be hurt, whether by a loved one’s actions, our own blindspots, or even just the passage of time. 

It’s part of the human condition that pain and meaning are opposite ends of the same coin. We may value health but inevitably get sick. Similarly, we may have a burning passion for our work but are destined to make mistakes.

From an ACT therapy perspective, it’s not the psychological pain itself that is viewed as the problem, but our responses to the pain. These responses typically lead to behaviors intended to avoid discomfort. 

Avoidance itself isn’t a problem per se, but it can certainly develop into one if avoidance becomes an embedded pattern in one’s life that begins interfering with valued living. This process is known as “psychological inflexibility” in ACT speak.

When we are psychologically inflexible, we operate primarily based on an over-attachment to our thoughts and an aversion to painful feelings or sensations. 

This way of behaving can make it difficult to see things clearly or act effectively. It usually creates even more suffering and stuckness in the long term. 

The primary aim of acceptance and commitment therapy is to help clients develop increased psychological flexibility, or the capacity to maintain or adjust behavior according to values within a specific situation.

When we are psychologically flexible, we can stay connected with our values and act authentically and in freely chosen ways. The original pain may still be there, but we can navigate the pain in a way that feels empowered and meaningful.

There are six core processes in ACT therapy that explain how we become more psychologically flexible. 

All ACT conceptualizations and interventions are based on exploring how these principles show up for our clients and ways to increase psychological flexibility. 

It’s important to note that while each process adds value independently, there is also much overlap and interplay between all ACT processes.

6 core processes of psychological flexibility in acceptance and commitment therapy

1. Cognitive defusion

Take a moment and imagine two pieces of metal that are “fused” together. The two separate pieces become one piece, and there is no longer any differentiation. When we are “fused” with our thoughts, we essentially “become our thoughts” and lose sight of the fact that we are the thinkers, not the thoughts.

When operating under a state of cognitive fusion, our behavior is more easily influenced by the thoughts in our awareness, even when they are unhelpful or actively harmful. 

Cognitive defusion skills help our clients step back and notice that we can observe thoughts without needing to engage with them. There are so many powerful and experiential tools to help increase defusion.

One of my favorites is to have clients preface a thought with the statement, “I notice I’m having the thought that…” 

For example, if a client is fused with the thought “I am a failure,” they can practice telling themselves, “I notice I’m having the thought that I’m a failure.” It’s hard not to feel at least a bit of space between ourselves and our thoughts when we do this.

2. Acceptance

A core aspect of psychological inflexibility is experiential avoidance, or engaging in all sorts of mental or physical behaviors to escape from discomfort (e.g., thoughts, feelings, memories, sensations, etc). 

Acceptance skills aim to help our clients create space for difficult or unwanted internal experiences. 

Clients may feel like they’re in a never-ending tug-of-war fight with their discomfort. They tug one way, their anxiety tugs back the other way, and on and on it goes, leading to exhaustion and hopelessness. 

In ACT therapy, we want to help our clients understand the futility of this fight and how to ultimately “drop the rope.” Anxiety will still be present, but our clients will be free to spend their energy on things that bring them fulfillment.

3. Present-moment awareness

When caught up trying to avoid painful experiences, it’s easy to be taken out of the present moment, whether it’s by numbing ourselves with substances or social media, ruminating about the past, or worrying about the future. 

All change begins with awareness of the present moment—the only moment anybody truly has. 

Returning to the present allows clients to slow down. It provides the foundation for clients to start breaking long-standing patterns of avoidance and fusion. Acceptance and commitment therapy aims to help clients attune to the here and now using mindfulness and other attentional control strategies.

4. Self-as-context

Self-as-context often confuses therapists the most of all the acceptance and commitment therapy processes. 

When people are psychologically inflexible, they tend to be tightly fused to various aspects of their identity or life narratives. For example, it’s not necessarily a “bad” thing to view oneself as a “hard worker.” However, if that identity is held rigidly in contexts that don’t serve the individual, it could very well lead to burnout, anxiety, and stress. 

Self-as-context entails assisting clients in broadening their perspective-taking repertoires, allowing them to see their various identities and self-narratives with flexibility and a sense of empowerment.

5. Values

The emphasis on values is what many people find the richest contribution by ACT. 

In acceptance and commitment therapy, identifying and connecting with values is everything. Friedrich Nietzsche said, “He who has a why, can bear any how.” This quote was famously used by Victor Frankl in his book “Man’s Search for Meaning.” 

In ACT therapy, values are the “why.” 

Once our clients can allow painful feelings and detach from unhelpful thinking, values are the guiding light that shows them what to do with their next step forward. 

Values are defined as present-moment qualities of action. They can fall into many different domains, such as family (e.g., being nurturing or present), occupation (e.g., hardworking, consciousness), health (e.g., taking care of one’s body and mind), and personal growth (e.g., creating, learning, teaching).

6. Committed action

Many people mistake the ACT process of “committed action” to mean committing to do something in the future (e.g., “I am going to commit to exercising five days per week”), but this is not the case. 

Committed action in ACT therapy is actually another present-moment process. It is the act of making a choice, in this moment, that is in line with one’s values. It’s similar to meditation. When one loses focus on their breath, they can commit to gently refocusing on their breath as soon as they know they have become distracted. 

One of the coolest things about acceptance and commitment therapy is that any intervention that is helpful for the individual and in service of their chosen values can be included in the “committed action” process. 

This often entails exposure therapy, social skills training, assertiveness skills, problem-solving, self-compassion, and much more.

What is acceptance and commitment therapy helpful for?

Acceptance and commitment therapy, by nature, is transdiagnostic, which means that it is helpful for many different forms of human suffering.

The research on the benefits of ACT has proliferated over the past several years. 

ACT therapy is effective for numerous conditions. Whether using ACT for anxiety disorders or ACT for OCD, the approach has shown promising results. 

It can also be effective for other challenges including depression, chronic pain, substance use, eating disorders, stress, and psychosis, and can be adapted for group therapy and different ages, from children to adults.

Furthermore, ACT cognitive therapy can often be seamlessly integrated into other evidence-based treatments, which can be especially helpful for clients who feel stuck or aren’t responding to traditional therapeutic modalities.

If you are interested in learning more about ACT and getting involved in the community, I’d highly recommend joining the Association for Contextual Behavioral Science, the professional organization that oversees the research and dissemination of ACT.

Looking for ACT therapy worksheets? These acceptance and commitment therapy worksheets are free to download, print, and use in your practice. 

Sources

• Dindo L, Van Liew JR, Arch JJ. (2017). Acceptance and commitment therapy: A transdiagnostic behavioral intervention for mental health and medical conditions. 
• Gloster AT, Walder N, Levin ME, Twohig MP, & Karekla M. (2020). The empirical status of acceptance and commitment therapy: A review of meta-analyses.

How SimplePractice streamlines running your practice

SimplePractice is HIPAA-compliant practice management software with everything you need to run your practice built into the platform—from booking and scheduling to insurance and client billing.

If you’ve been considering switching to an EHR system, SimplePractice empowers you to run a fully paperless practice—so you get more time for the things that matter most to you.

Try SimplePractice free for 30 days. No credit card required.