Acceptance and Commitment Therapy (ACT)

Presentation

Acceptance and Commitment Therapy (ACT, pronounced as the word 'act') is a third-wave cognitive-behavioral therapy approach developed in the 1980s by Steven C. Hayes, psychology professor at the University of Nevada. Unlike classical CBT which seeks to modify dysfunctional thoughts, ACT aims to change the person's relationship with their painful thoughts and emotions.

ACT is grounded in Relational Frame Theory (RFT), a theory of human language and cognition. Its primary goal is to develop psychological flexibility — the ability to be fully present, accept internal experiences (even unpleasant ones) and act in alignment with deep values, even in the presence of suffering.

Founder: Steven C. Hayes (born 1948), psychology professor, University of Nevada

Core Principles

ACT revolves around six core processes forming the hexaflex of psychological flexibility:

1. Cognitive defusion: learning to observe thoughts as mere mental events without identifying with or fighting them. Techniques: 'I'm having the thought that...', bus metaphor, leaves on a stream.

2. Acceptance: welcoming unpleasant emotions and sensations without trying to avoid, control or suppress them. The opposite of experiential avoidance.

3. Contact with the present moment: developing full and flexible awareness of the here and now, similar to mindfulness.

4. Self-as-context: connecting with a stable, observing sense of self distinct from the changing content of thoughts and emotions (the 'observing self').

5. Values: clarifying what truly matters — chosen life directions rather than goals to achieve.

6. Committed action: implementing concrete actions aligned with values while accepting internal obstacles that may arise.

Main Indications

• Depression and recurrent depressive episodes
• Anxiety disorders (generalized anxiety, social phobia)
• Chronic pain and fibromyalgia
• Burnout and professional exhaustion
• Addictions (tobacco, alcohol, substances)
• Eating disorders
• Obsessive-compulsive disorders
• Tinnitus and somatoform disorders
• Stress management and relapse prevention

Session Overview

An ACT session typically lasts 50 to 60 minutes. The therapist extensively uses metaphors, experiential exercises and role-plays to convey concepts. A typical session may begin with a brief mindfulness exercise, followed by discussion of the week's experiences in relation to identified values.

Core work may involve a defusion exercise (e.g., repeating an anxious thought until it loses its grip), an acceptance exercise (welcoming a difficult emotion with curiosity), or values clarification work. The session concludes with defining concrete committed actions to complete before the next appointment. The standard protocol comprises 8 to 16 sessions.

Variations and Sub-techniques

• ACT for chronic pain
• ACT for addictions (ACT + skills training)
• Group ACT (manualized protocols)
• DNA-V (ACT adapted for adolescents)
• Online ACT and digital applications
• ACT for burnout and workplace well-being

Contraindications

• Acute psychotic episode with mental confusion
• Imminent unstabilized suicidal risk
• Severe dissociative state (acceptance may worsen dissociation)
• Severe cognitive impairment preventing metaphor comprehension
• Patient refusal to engage in experiential exercises