What is Acceptance and Commitment Therapy (ACT)?

ACT is an evidence-based therapy that focuses on increasing psychological flexibility by fostering acceptance of internal experiences and encouraging action in line with personal values.

When is ACT indicated?

ACT is recommended for depression, anxiety, chronic pain, substance use disorders, and emotional dysregulation. It is especially useful for patients with high experiential avoidance or resistance to traditional cognitive restructuring.

ACT promotes mindfulness, acceptance, and committed action. It teaches patients to relate differently to their thoughts and emotions and to pursue meaningful life directions despite psychological pain.

How long does ACT last?

ACT typically involves 8 to 20 sessions, depending on the patient's needs and clinical context. The focus is on learning skills that promote long-term psychological flexibility.

Is ACT effective for depression?

Yes, ACT is effective in reducing depressive symptoms and improving well-being. It is particularly beneficial for patients with chronic rumination, experiential avoidance, or resistance to cognitive restructuring.

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Acceptance and Commitment Therapy (ACT)

Acceptance and Commitment Therapy (ACT) is a psychotherapeutic approach belonging to the so-called third wave of cognitive-behavioral therapy. Developed by Steven C. Hayes and colleagues, ACT is based on the premise that many psychological disorders, including depression, arise from rigid and unsuccessful attempts to avoid or control unpleasant thoughts and emotions, rather than from their mere presence.

The goal of ACT is not to suppress or modify negative mental content, but to develop psychological flexibility: the ability to stay in contact with the present moment, accept internal experiences, and act in accordance with one’s core values, even in the presence of suffering.

Theoretical Model and Clinical Rationale

ACT is grounded in the Relational Frame Theory (RFT), a theory of language and cognition that explains how people construct meaning through learned verbal relations. According to ACT, the mind constantly creates verbal associations between experiences, emotions, and evaluations (“I’m sad → I’m worthless → Nothing will ever change”), which become sources of suffering when they are experienced as absolute and immutable truths.

Attempts to control these thoughts and feelings—referred to as experiential avoidance—ultimately increase distress, reduce vitality, and restrict behavioral repertoires. In depression, this manifests as social withdrawal, disengagement from meaningful activities, cognitive rigidity, and disconnection from personal values.

Therapy Structure and Core Processes

ACT does not focus on diagnosis or symptoms per se, but instead promotes six interrelated psychological competencies that support the development of psychological flexibility:

Acceptance: openness and willingness to experience internal states without attempting to avoid or modify them;
Cognitive defusion: observing one’s thoughts as transient mental events, not as absolute truths or instructions to follow;
Present-moment awareness: maintaining a connection with the present rather than ruminating on the past or worrying about the future;
Self-as-context: recognizing the observing self (the internal “witness”) as distinct from transient mental content (thoughts, emotions, memories);
Values clarification: identifying what truly matters to the patient, in terms of meaningful life direction;
Committed action: engaging in behavior aligned with personal values, even in the presence of psychological discomfort.

ACT typically includes 8 to 20 sessions and employs experiential exercises, therapeutic metaphors, mindfulness practices, and values-based work. The therapeutic stance is nonjudgmental, empathetic, and action-oriented, aiming to foster a meaningful life in the presence of pain.

Clinical Indications

ACT has shown particular efficacy in treating major depressive disorder, especially in cases characterized by chronic rumination, experiential avoidance, loss of personal meaning, and inflexible thinking patterns. It is also suitable for patients who resist classical cognitive restructuring or do not fully respond to traditional CBT.

In addition to depression, ACT is indicated for a wide range of clinical conditions, including:

Generalized anxiety disorder and social phobia;
Obsessive-compulsive disorder and somatization disorders;
Chronic pain and complex medical conditions with significant emotional impact;
Substance use disorders and emotional dysregulation issues (e.g., borderline personality disorder, PTSD);
Transdiagnostic interventions and promotion of psychological well-being in non-clinical settings (e.g., schools, workplaces, prevention programs).

Efficacy and Scientific Validation

Numerous randomized controlled trials (RCTs) and meta-analyses have confirmed ACT’s efficacy in reducing depressive symptoms and improving overall functioning. Its performance is comparable to that of traditional CBT, with some advantages in patients with pronounced avoidance, rumination, or psychosomatic comorbidities.

ACT has shown significant effects on psychological distress, subjective well-being, and quality of life. Therapeutic gains appear to be stable over time, particularly in patients who integrate acceptance with values-based action.

NICE guidelines cite ACT among emerging third-wave approaches. The APA recognizes it as an evidence-based model for anxiety and depression, and CANMAT recommends its use in depressive conditions marked by cognitive rigidity or resistance to standard treatment.

Final Considerations

Acceptance and Commitment Therapy represents a paradigm shift in psychotherapy: it does not aim to “cure” negative thoughts, but rather to develop the capacity to live a full and value-consistent life in the presence of pain. It is a deeply humanistic, flexible, and accessible model, suitable for patients with diverse functioning levels and complex clinical histories.

Its effectiveness depends on the therapist’s ability to guide the patient beyond the struggle with symptoms toward a mindful reclaiming of personal life direction. In this sense, ACT is not merely a therapy for depressive disorders but a clinical philosophy grounded in sustainable and profound change.

Bibliography

Hayes SC et al. Acceptance and Commitment Therapy: The Process and Practice of Mindful Change. 2nd ed. New York: Guilford Press; 2012.
A-Tjak JGL et al. A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems. Psychother Psychosom. 2015;84(1):30–36.
Öst LG. The efficacy of Acceptance and Commitment Therapy: An updated systematic review and meta-analysis. Behav Res Ther. 2014;61:105–121.
Powers MB et al. Acceptance and Commitment Therapy: A meta-analytic review. Psychother Psychosom. 2009;78(2):73–80.
Twohig MP, Levin ME. Acceptance and Commitment Therapy as a treatment for anxiety and depression: A review. Psychiatr Clin North Am. 2017;40(4):751–770.
Hayes SC et al. Psychological flexibility and the future of ACT research. Behav Modif. 2006;30(6):803–814.
Forman EM et al. A randomized controlled effectiveness trial of Acceptance and Commitment Therapy and Cognitive Therapy for anxiety and depression. Behav Modif. 2007;31(6):772–799.
National Institute for Health and Care Excellence (NICE). Depression in adults: treatment and management. NICE guideline [NG222]. 2022.
American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder. 3rd ed. 2010.
Canadian Network for Mood and Anxiety Treatments (CANMAT). Clinical guidelines for the management of major depressive disorder in adults. Can J Psychiatry. 2016;61(9):510–523.