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.
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 is a form of psychotherapy developed within the behavioral tradition and rooted in relational frame theory. It is often described as a "third-wave" cognitive-behavioral therapy because it emphasizes a person's relationship to their thoughts and emotions rather than the direct modification of thought content. The central goal is psychological flexibility — the capacity to stay in contact with the present moment and to act in line with one's values even in the presence of difficult internal experiences.
ACT organizes its work around six interrelated core processes: acceptance (making room for unwanted thoughts and feelings), cognitive defusion (stepping back from thoughts so they are seen as passing mental events), present-moment awareness, self-as-context (a flexible sense of self that observes experience), values clarification, and committed action. Practitioners typically weave mindfulness exercises, metaphors, and experiential work through these processes rather than following a fixed script.
A defining feature of ACT is that it does not treat symptom reduction as the primary target. Where more traditional cognitive-behavioral approaches often work to identify and dispute distorted thoughts, ACT encourages people to notice thoughts without being controlled by them, while redirecting energy toward valued living. Symptom improvement, when it occurs, is generally viewed as a byproduct of increased psychological flexibility.
ACT is considered transdiagnostic, meaning the same underlying processes are applied across many different presentations rather than being tailored to a single diagnosis. Research has examined ACT for anxiety, depression, chronic pain, stress, and a range of other health-related concerns, and it may be delivered individually, in groups, or through guided internet-based programs.
What to Expect
- Initial assessment and collaborative discussion of the person's concerns, goals, and the ways current coping strategies may be narrowing their 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 the person explores what they want their life to stand for across areas such as relationships, work, and health.
- Goal-setting and committed action, translating 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 circumstances change.
How does Acceptance and Commitment Therapy work?
- ACT proposes that much psychological suffering is maintained by psychological inflexibility, in which efforts to avoid or suppress unwanted thoughts and feelings paradoxically narrow a person's behavior and pull them away from what matters to them. The therapy targets this process rather than the specific content of any single thought.
- Acceptance and cognitive defusion techniques aim to reduce the struggle with internal experiences. By practicing openness to emotions and learning to observe thoughts as mental events rather than literal truths, people may become less driven to avoid or react to them.
- Present-moment awareness and self-as-context work help cultivate a flexible, observing perspective, so that difficult experiences can be noticed without being fused with one's identity. Mindfulness exercises are often used to support this shift in stance.
- Values clarification and committed action translate this openness into behavior change. Once a person identifies what they care about, they work with the clinician to set and pursue concrete goals, so that day-to-day choices increasingly reflect their values even 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
Is a acceptance and commitment therapy right for you?
Reach out to learn more from Mario A. Benitez-Lopez.
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 (ACT) is a mindfulness-based form of cognitive-behavioral therapy that helps people build psychological flexibility. Rather than trying to eliminate difficult thoughts and feelings, it teaches skills for accepting them while taking action guided by personal values.
- ACT does not involve any physical procedures, but it does ask people to turn toward thoughts and feelings they may usually avoid. This can feel challenging or temporarily increase distress, and many people find that the discomfort eases as they build new skills. 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. As with any therapy, working through difficult experiences can be demanding, so it is best pursued with appropriate professional support.
- The number of sessions varies with a person's goals and circumstances. Some people benefit from a brief course of a few sessions, while others engage in longer or periodic work. Sessions are often scheduled weekly or biweekly, and the plan is typically reviewed over time.
- Sessions often blend discussion, mindfulness exercises, and metaphors to practice accepting difficult experiences and stepping back from unhelpful thoughts. A clinician typically helps clarify what matters most to you and set concrete goals, with between-session practice to apply the skills in daily life.
- People in acute crisis or requiring immediate stabilization may need higher-intensity care first, and ACT is not a substitute for medically indicated treatment. Because the approach relies on abstract reasoning and perspective-taking, suitability is assessed individually with a qualified clinician.
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: 2026-07-26