A comprehensive resource for therapists on Acceptance and Commitment Therapy: understanding psychological flexibility, the hexaflex model, and practical applications in clinical practice.
Acceptance and Commitment Therapy (ACT, pronounced as the word "act") is a modern, evidence-based form of psychotherapy that falls under the umbrella of third-wave cognitive-behavioral therapies. Developed by Steven Hayes in the 1980s, ACT is based on Relational Frame Theory (RFT) and focuses on psychological flexibility rather than symptom reduction.
Unlike traditional CBT, which focuses on changing thoughts and feelings, ACT teaches clients to accept their internal experiences (thoughts, feelings, sensations) while committing to actions aligned with their values. The goal is not to eliminate suffering but to live a meaningful life even in the presence of difficult experiences.
ACT is transdiagnostic, meaning it can be applied across a wide range of psychological conditions. It's particularly effective for chronic conditions, treatment-resistant cases, and when clients struggle with experiential avoidance.
The central goal of ACT is to increase psychological flexibility—the ability to be present, open up, and do what matters. Psychological flexibility is achieved through six core processes, often visualized as the "hexaflex" model:
Willingness to experience thoughts, feelings, and sensations as they are, without trying to change, avoid, or control them. This is the opposite of experiential avoidance.
Learning to see thoughts as thoughts—mental events rather than facts. This reduces the literal impact of thoughts and allows clients to respond flexibly rather than automatically.
Being fully present and engaged in the here and now, rather than being caught up in the past or worried about the future. This is cultivated through mindfulness practices.
Developing a sense of self as the observer of experiences rather than being fused with thoughts, feelings, or roles. This creates psychological space and perspective.
Identifying what truly matters—chosen life directions that are meaningful and important. Values are ongoing actions, not goals to be achieved.
Taking effective action guided by values, even in the presence of difficult thoughts and feelings. This involves setting goals and persisting despite obstacles.
ACT uses numerous metaphors and experiential exercises to teach concepts:
ACT incorporates mindfulness exercises to develop present-moment awareness, acceptance, and defusion. These may include breathing exercises, body scans, and mindful observation of thoughts and feelings.
Clients identify their values across life domains (relationships, work, health, personal growth, etc.) and explore what truly matters to them. Values are distinguished from goals and rules.
Clients set specific, concrete goals aligned with values and develop action plans. They learn to persist despite obstacles and "uncomfortable" internal experiences.
In-session exercises help clients experience defusion, acceptance, and values in action. These are often more powerful than didactic teaching.
ACT has strong research support and is effective for a wide range of conditions:
Depression, Anxiety disorders, PTSD, OCD, Substance use disorders, Eating disorders, Psychosis, Chronic pain
Workplace stress, Performance enhancement, Grief and loss, Chronic illness, Treatment-resistant conditions, Prevention and wellness
Research shows ACT is as effective as traditional CBT for many conditions, with some studies showing superior outcomes, particularly for chronic conditions and when experiential avoidance is a key factor. ACT is recognized as an empirically supported treatment by the American Psychological Association.
Flexible Structure: ACT doesn't follow a rigid protocol. Sessions are flexible and responsive to client needs, though therapists typically address all six processes over time.
Experiential Focus: ACT emphasizes experiential learning over intellectual understanding. Use exercises, metaphors, and in-session experiences rather than just explaining concepts.
Workability: The key question in ACT is "Does this work?" Focus on what helps clients live according to their values, not on whether thoughts are "true" or feelings are "right."
Creative Hopelessness: Help clients recognize that their attempts to control or avoid difficult experiences haven't worked long-term. This opens the door to acceptance-based approaches.
Values-Based Living: Regularly connect actions to values. Help clients see that meaningful living involves discomfort, and that's okay.
ACT training is available through various organizations, including the Association for Contextual Behavioral Science (ACBS). Training typically includes:
Certification is available through ACBS. Ongoing training, consultation, and personal practice of ACT principles are important for effective implementation.
ACT has specific considerations:
PracFlow supports ACT practice with flexible documentation, values tracking, committed action planning, and outcome measurement tools.