![A garden path running on through thistles towards a sunlit orchard](https://viacara.com/img/content/approaches-acceptance-and-commitment-therapy-feature-light.webp)

# Acceptance and Commitment Therapy (ACT)

Learn how acceptance and commitment therapy (ACT) works, what NICE says about it for long-term pain and what research shows for anxiety and low mood.

## What is acceptance and commitment therapy?

Acceptance and commitment therapy (ACT) works on how you respond to painful thoughts and feelings. Rather than fight them, you learn to make room for them. Then you put your energy into what matters to you.

You say it as one word, "act". Steven Hayes, Kirk Strosahl and Kelly Wilson developed it.

ACT belongs to a newer "third wave" of therapies that grew out of behavioural and cognitive therapy. The same wave includes [dialectical behaviour therapy](https://viacara.com/approaches/dbt/) and [mindfulness-based cognitive therapy](https://viacara.com/approaches/mindfulness-based-therapy/).

Sources: [ACBS: ACT resources](https://viacara.com/approaches/acceptance-and-commitment-therapy/#ref-1), [Hayes et al. 2011](https://viacara.com/approaches/acceptance-and-commitment-therapy/#ref-2), [Hayes et al. 2006](https://viacara.com/approaches/acceptance-and-commitment-therapy/#ref-3)

## How it *works*

Most of us try to push painful feelings away. We avoid what sets them off, distract ourselves or argue with them in our heads.

Hayes and his colleagues call this experiential avoidance. They argue that trying to avoid a feeling tends to make it matter more, not less.

ACT aims instead for what it calls psychological flexibility. That means being fully present, and changing or keeping up what you do when it serves what you value.

Six connected *ACT* processes

- **Acceptance** Making room for difficult feelings.
- **Defusion** Seeing a thought as a thought, rather than an instruction.
- **Being present** Noticing what is happening now.
- **Self as context** Noticing experiences without reducing the self to one thought or label.
- **Values** Identifying what matters to the client.
- **Committed action** Taking steps towards those values.

A therapist draws on these connected processes. They are not six stages to complete in order.

ACT focuses on how a client relates to thoughts, rather than only testing whether each thought is true.

Sources: [Hayes et al. 2006](https://viacara.com/approaches/acceptance-and-commitment-therapy/#ref-3), [ACBS: ACT model](https://viacara.com/approaches/acceptance-and-commitment-therapy/#ref-11)

## What *sessions* look like

An ACT therapist uses mindfulness exercises and metaphors, not only talk. You will also explore what matters to you in different parts of life, such as family or work.

Between sessions, you take small steps towards those values. You also notice what gets in the way, and work through it with your therapist.

Source: [Hayes et al. 2006](https://viacara.com/approaches/acceptance-and-commitment-therapy/#ref-3)

![Further along the path, the orchard closer and the thistles still in flower](https://viacara.com/img/content/approaches-acceptance-and-commitment-therapy-mid-light.webp)

ACT does not clear the path first. You walk it with the thistles still there.

## Who is it best *suited* to?

For chronic primary pain, NICE says to consider ACT or CBT for pain. That is for people aged 16 and over, from a professional with the right training.

Chronic primary pain has no clear underlying condition, or it is out of proportion to any injury or disease. Fibromyalgia is one example. Our [chronic illness page](https://viacara.com/support/chronic-illness/) covers living with long-term pain.

ACT can be a good fit if you:

- Live with long-term pain, and the fight against it has taken over your life
- Keep getting caught in arguments with your own thoughts
- Avoid people, places or plans because of how they make you feel
- Want to work out what matters to you, and live closer to it
- Tried CBT, but questioning each thought did not stick

Source: [NICE NG193](https://viacara.com/approaches/acceptance-and-commitment-therapy/#ref-4)

## ACT or *CBT*?

Hayes and his colleagues say ACT aims to change your relationship with a thought, rather than the thought itself. By contrast, [CBT](https://viacara.com/approaches/cbt/) more often tests a thought and looks for a more balanced one.

|  | CBT | ACT |
| --- | --- | --- |
| A painful thought | Test it and look for a more balanced view | Notice it as a thought, and let it be there without obeying it |
| What changes | The thought itself | Your relationship with the thought |
| Progress looks like | The thought loses its grip | You do more of what matters, with or without the thought |

For chronic primary pain, NICE found too little evidence to prefer either one. Reviews across other problems point the same way. So choose the way of working that suits you.

Sources: [Hayes et al. 2006](https://viacara.com/approaches/acceptance-and-commitment-therapy/#ref-3), [NICE NG193](https://viacara.com/approaches/acceptance-and-commitment-therapy/#ref-4), [A-Tjak et al. 2015](https://viacara.com/approaches/acceptance-and-commitment-therapy/#ref-7), [Gloster et al. 2020](https://viacara.com/approaches/acceptance-and-commitment-therapy/#ref-8)

## The *evidence*

Most of the evidence NICE reviewed showed ACT improved quality of life and sleep, and reduced pain and distress. It came from a fairly small number of studies.

A 2015 review of 39 trials found ACT did better than waiting lists, usual care and placebo therapies. Against established treatments such as CBT, it found no clear difference.

A 2020 study drew together 20 earlier reviews. It judged ACT effective for anxiety, depression, substance use and pain. ACT did better than most comparisons, but not better than CBT.

Sources: [NICE NG193](https://viacara.com/approaches/acceptance-and-commitment-therapy/#ref-4), [A-Tjak et al. 2015](https://viacara.com/approaches/acceptance-and-commitment-therapy/#ref-7), [Gloster et al. 2020](https://viacara.com/approaches/acceptance-and-commitment-therapy/#ref-8)

## Where the evidence *stops*

The pain research is less settled than NICE's recommendation might suggest. A 2017 review of 11 trials found people accepted their pain more after ACT. It found no clear change in how much pain they felt, or in their quality of life.

A 2020 Cochrane review rated every ACT outcome for chronic pain as very low quality evidence. Its authors said they were very uncertain whether ACT helps.

NICE's guidelines on depression and on generalised anxiety disorder do not name ACT. If you have one of those diagnoses, ask about the therapies NICE does name, such as CBT, as well.

Not sure ACT fits? Our [guide to the different approaches](https://viacara.com/guides/understanding-approaches/) starts from what you want, not from the name of a therapy.

Sources: [Hughes et al. 2017](https://viacara.com/approaches/acceptance-and-commitment-therapy/#ref-9), [Fisher et al. 2020](https://viacara.com/approaches/acceptance-and-commitment-therapy/#ref-10), [NICE NG222](https://viacara.com/approaches/acceptance-and-commitment-therapy/#ref-5), [NICE CG113](https://viacara.com/approaches/acceptance-and-commitment-therapy/#ref-6)

On this page

[What is acceptance and commitment therapy?](https://viacara.com/approaches/acceptance-and-commitment-therapy/#what-is-acceptance-and-commitment-therapy) [How it works](https://viacara.com/approaches/acceptance-and-commitment-therapy/#how-it-works) [What sessions look like](https://viacara.com/approaches/acceptance-and-commitment-therapy/#what-sessions-look-like) [Who is it best suited to?](https://viacara.com/approaches/acceptance-and-commitment-therapy/#who-is-it-best-suited-to) [ACT or CBT?](https://viacara.com/approaches/acceptance-and-commitment-therapy/#act-or-cbt) [The evidence](https://viacara.com/approaches/acceptance-and-commitment-therapy/#the-evidence) [Where the evidence stops](https://viacara.com/approaches/acceptance-and-commitment-therapy/#where-the-evidence-stops)

Related

[Cognitive Behavioural Therapy (CBT)](https://viacara.com/approaches/cbt/) [Mindfulness-Based Cognitive Therapy](https://viacara.com/approaches/mindfulness-based-therapy/) [Compassion-Focused Therapy (CFT)](https://viacara.com/approaches/compassion-focused-therapy/) [Chronic Illness and Long-Term Conditions](https://viacara.com/support/chronic-illness/) [Understanding Anxiety](https://viacara.com/support/anxiety/) [Understanding Different Approaches](https://viacara.com/guides/understanding-approaches/)

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## References

1. Association for Contextual Behavioral Science (2026). *Acceptance and Commitment Therapy (ACT) resources*. [contextualscience.org](https://contextualscience.org/acceptance_commitment_therapy_resources)
2. Hayes, S. C., Strosahl, K. D. & Wilson, K. G. (2011). *Acceptance and Commitment Therapy: The Process and Practice of Mindful Change, second edition*. Guilford Press. [guilford.com](https://www.guilford.com/books/Acceptance-and-Commitment-Therapy/Hayes-Strosahl-Wilson/9781462528943)
3. Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A. & Lillis, J. (2006). *Acceptance and commitment therapy: Model, processes and outcomes*. Behaviour Research and Therapy. [doi:10.1016/j.brat.2005.06.006](https://doi.org/10.1016/j.brat.2005.06.006)
4. National Institute for Health and Care Excellence (2021). *Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain (NG193)*. [nice.org.uk](https://www.nice.org.uk/guidance/ng193)
5. National Institute for Health and Care Excellence (2022). *Depression in adults: treatment and management (NG222)*. [nice.org.uk](https://www.nice.org.uk/guidance/ng222)
6. National Institute for Health and Care Excellence (2011). *Generalised anxiety disorder and panic disorder in adults: management (CG113)*. [nice.org.uk](https://www.nice.org.uk/guidance/cg113)
7. A-Tjak, J. G. L., Davis, M. L., Morina, N., Powers, M. B., Smits, J. A. J. & Emmelkamp, P. M. G. (2015). *A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems*. Psychotherapy and Psychosomatics. [doi:10.1159/000365764](https://doi.org/10.1159/000365764)
8. Gloster, A. T., Walder, N., Levin, M. E., Twohig, M. P. & Karekla, M. (2020). *The empirical status of acceptance and commitment therapy: A review of meta-analyses*. Journal of Contextual Behavioral Science. [doi:10.1016/j.jcbs.2020.09.009](https://doi.org/10.1016/j.jcbs.2020.09.009)
9. Hughes, L. S., Clark, J., Colclough, J. A., Dale, E. & McMillan, D. (2017). *Acceptance and commitment therapy (ACT) for chronic pain: A systematic review and meta-analyses*. The Clinical Journal of Pain. [doi:10.1097/AJP.0000000000000425](https://doi.org/10.1097/AJP.0000000000000425)
10. Williams, A. C. de C., Fisher, E., Hearn, L. & Eccleston, C. (2020). *Psychological therapies for the management of chronic pain (excluding headache) in adults*. Cochrane Database of Systematic Reviews. [doi:10.1002/14651858.CD007407.pub4](https://doi.org/10.1002/14651858.CD007407.pub4)
11. Association for Contextual Behavioral Science (2026). *About ACT*. [contextualscience.org](https://contextualscience.org/about_act)

## Related

### [Cognitive Behavioural Therapy (CBT)](https://viacara.com/approaches/cbt/)

Learn how CBT works, what happens in sessions and what NICE says about it, and read about its forms for sleep, pain and self-help.

### [Mindfulness-Based Cognitive Therapy](https://viacara.com/approaches/mindfulness-based-therapy/)

Learn how mindfulness-based cognitive therapy (MBCT) works, why NICE recommends it to stop depression returning and how it differs from MBSR.

### [Compassion-Focused Therapy (CFT)](https://viacara.com/approaches/compassion-focused-therapy/)

Learn how compassion-focused therapy (CFT) works with shame and a harsh inner critic, what sessions involve and what the research shows so far.

### [Chronic Illness and Long-Term Conditions](https://viacara.com/support/chronic-illness/)

A long-term condition is hard on your mind as well as your body. Find a professional who works with the emotional side, alongside your medical team.

### [Understanding Anxiety](https://viacara.com/support/anxiety/)

Learn about anxiety, its symptoms and how therapy can help. Find the right practitioner for anxiety support.

### [Understanding Different Approaches](https://viacara.com/guides/understanding-approaches/)

A plain-English guide to the main therapeutic approaches including CBT, person-centred therapy, psychodynamic and integrative methods.