Acceptance and Commitment Therapy in San Francisco
Acceptance and Commitment Therapy (ACT) is a third-wave, mindfulness-based form of cognitive-behavioral therapy that aims to build psychological flexibility rather than eliminate difficult thoughts or feelings. Instead of disputing the content of distressing thoughts, ACT helps people change their relationship to those inner experiences while clarifying personal values and committing to actions that move life in a meaningful direction. It is used across a range of conditions, including anxiety, depression, chronic pain, and stress. I rarely book ACT as a separate course of therapy. It runs inside medication management: willingness, defusion, and values work carried alongside the prescribing itself.
At a Glance
- ACT centers on six core processes – acceptance, cognitive defusion, present-moment awareness, self-as-context, values clarification, and committed action – that together aim to build psychological flexibility[1]
- Rather than challenging or disputing the content of difficult thoughts, ACT works to change a person's relationship to those thoughts so they hold less influence over behavior[1]
- A 2023 meta-analysis of 11 randomized controlled trials involving 962 participants found ACT was associated with reduced depressive symptoms, though the authors noted substantial heterogeneity across studies[2]
- A systematic review of 39 randomized controlled trials reported small effects of internet-delivered ACT on anxiety and depressive symptoms compared with control conditions[3]
Overview
Acceptance and Commitment Therapy developed within the behavioral tradition and is rooted in relational frame theory. It is often described as a third-wave form of cognitive-behavioral therapy. Rather than trying to change the content of every difficult thought, ACT works on how you relate to thoughts and emotions. Its central goal is psychological flexibility – staying in contact with the present moment and acting in line with your values even when difficult internal experiences are present.
ACT organizes that work around six connected processes: acceptance, cognitive defusion, present-moment awareness, self-as-context, values clarification, and committed action. Acceptance involves making room for unwanted thoughts and feelings. Defusion means stepping back from thoughts and seeing them as passing mental events. Self-as-context develops a more flexible, observing sense of self. Practitioners typically use mindfulness exercises, metaphors, and experiential work across these processes rather than following a fixed script.
ACT does not treat symptom reduction as its primary target. Traditional cognitive-behavioral approaches often identify and dispute distorted thoughts. ACT instead asks you to notice thoughts without letting them control your behavior, then redirect your effort toward the life you want to live. When symptoms improve, ACT generally views that improvement as a byproduct of greater psychological flexibility.
ACT is transdiagnostic: the same underlying processes can be applied across different presentations rather than being reserved for one diagnosis. Research has examined it for anxiety, depression, chronic pain, stress, and other health-related concerns. It may be delivered individually, in groups, or through guided internet-based programs.
What to Expect
- An initial assessment and collaborative discussion of your concerns, goals, and how current coping strategies may be narrowing your life.
- Introduction to the ACT model, often including the idea that struggling against unwanted thoughts and feelings can be part of the problem rather than the solution.
- Acceptance and defusion work, using experiential exercises and metaphors to practice making room for difficult experiences and holding thoughts more lightly.
- Mindfulness and present-moment exercises to strengthen the ability to notice experience as it unfolds without automatic reaction.
- Values clarification, in which you work out what you want your life to stand for across areas such as relationships, work, and health.
- Goal-setting and committed action, translating your values into specific, achievable behaviors and troubleshooting barriers between sessions.
- Ongoing review of progress, with continued practice of the six core processes and adjustment of goals as your circumstances change.
How does Acceptance and Commitment Therapy work?
- ACT proposes that much psychological suffering is maintained by psychological inflexibility. Repeated efforts to avoid or suppress unwanted thoughts and feelings can paradoxically narrow your behavior and pull you away from what matters to you. ACT targets that pattern rather than the specific content of one thought.
- Acceptance and cognitive defusion are used to reduce the struggle with internal experiences. You practice being open to emotions and observing thoughts as mental events rather than literal truths. With practice, those thoughts and emotions may have less influence over avoidance and automatic reactions.
- Present-moment awareness and self-as-context develop a more flexible, observing perspective. Difficult experiences can be noticed without becoming fused with your identity. Mindfulness exercises are often used to support this change in stance.
- Values clarification and committed action carry that openness into daily behavior. Once you identify what you care about, you work with the clinician to set and pursue concrete goals. The aim is for day-to-day choices to reflect your values more consistently, including when discomfort is present.
When It's Recommended
- Anxiety disorders, including generalized anxiety and social anxiety
- Depression and persistent low mood
- Chronic pain and adjustment to long-term physical health conditions
- Stress and difficulties coping with distressing thoughts or emotions
- Situations where experiential avoidance and psychological inflexibility are prominent
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Recovery & Aftercare
- ACT is generally a skills-based process, and many people continue to apply acceptance, defusion, and values-based techniques well after formal sessions end
- Gains often build gradually as psychological flexibility increases, and some research suggests benefits may be maintained at follow-up, though effects can diminish over longer periods
- The length of treatment varies with the person's goals and circumstances; some benefit from a brief course while others engage in longer or periodic work
- Ongoing self-practice and, when helpful, occasional check-ins can support maintenance of skills
Alternative Treatments
- Traditional cognitive-behavioral therapy (CBT)
- Mindfulness-based cognitive therapy or mindfulness-based stress reduction
- Other evidence-based psychotherapies such as dialectical behavior therapy for relevant concerns
- Psychiatric medication management, considered alone or in combination with psychotherapy
Frequently Asked Questions
- Acceptance and Commitment Therapy, or ACT, is a mindfulness-based form of cognitive-behavioral therapy that builds psychological flexibility. It does not require you to eliminate difficult thoughts and feelings. Instead, you learn to make room for them, loosen their influence over your behavior, and take action guided by your values.
- ACT involves no physical procedure, but it does ask you to turn toward thoughts and feelings you may usually avoid. That can feel challenging or temporarily increase distress. Many people find the discomfort eases as they develop the skills, and working at a manageable pace with a clinician can help.
- ACT is generally considered a safe, well-tolerated psychotherapy when delivered by a qualified clinician. Working through difficult experiences can still be demanding, so it is best pursued with appropriate professional support.
- There is no fixed number. Some people benefit from a brief course of a few sessions, while others continue for longer or return for periodic work. Sessions are often weekly or biweekly, and the plan is typically reviewed over time as your goals and circumstances change.
- Sessions often combine discussion, mindfulness exercises, and metaphors. You practice making room for difficult experiences, stepping back from thoughts that are driving your behavior, and identifying what matters to you. A clinician typically helps you turn those values into concrete goals, with between-session practice to use the skills in daily life.
- Someone in an acute crisis or needing immediate stabilization may need higher-intensity care first. ACT is not a substitute for medically indicated treatment. It also relies in part on abstract reasoning and perspective-taking, which may be difficult for some people, so suitability is assessed individually with a qualified clinician.
- You usually do not need to decide in advance. The two approaches place different emphasis on a distressing thought: CBT examines whether it holds up, while ACT works on loosening its grip without arguing with its content. Which approach helps is often clearer a few sessions in than it is at the start. Because I practice both, that assessment requires no referral or new intake. If a thought responds better to being tested than to being held lightly, we can change approach and continue.
- No. Most of the ACT I practice happens inside medication management. Acceptance, defusion, and values work can be part of the conversation already taking place about what you want your life to look like. A dedicated course of therapy is also available if you prefer.
What are the risks of Acceptance and Commitment Therapy?
Who should avoid this
- Acute crises or conditions requiring immediate stabilization — such as active suicidality, severe agitation, or acute intoxication — generally need stabilization and higher-intensity care before values-based psychotherapy is appropriate
- ACT is not a substitute for medically indicated treatment; conditions that require medication, medical management, or other established interventions should be addressed through those means alongside or instead of therapy
- Evidence for ACT as a primary or standalone treatment in acute psychosis is limited, and it is generally not used as a replacement for indicated psychiatric care in that setting
- Approaches that rely on abstract reasoning and perspective-taking may be difficult for some individuals, and suitability is assessed on a case-by-case basis with a qualified clinician
Possible risks
- Practicing acceptance and turning toward previously avoided thoughts, feelings, or situations can temporarily increase distress before it eases
- ACT typically requires sustained practice between sessions, and benefits may be limited when exercises are not carried into daily life
- Symptoms may fluctuate over the course of therapy, and progress is often uneven rather than steadily linear
- This is not an exhaustive list; individual responses vary, and any concerns are best discussed with a qualified mental health clinician
Your practitioner
Mario A. Benitez-Lopez, MD
I am a board-certified adult psychiatrist and the founder of San Francisco Concierge Psychiatry. I completed my psychiatry residency at the University of Washington and hold a master's in clinical research from Stanford. I offer bilingual (English and Spanish) care in a concierge model built around small panels and longer sessions, spanning medication management, deprescribing, and evidence-based individual and couples therapy.
Sources & references
This article draws on 5 sources, including peer-reviewed research, leading medical institutions.
Government & research
Medical institutions
Medically reviewed by Mario A. Benitez-Lopez, MD · Last reviewed: 2026-08-31