Acceptance and Commitment Therapy

What Is ACT?

Acceptance and Commitment Therapy (pronounced as one word "act") is a form of psychotherapy that helps people live meaningful lives while accepting pain and difficult emotions rather than struggling against them.¹

The Core Idea

Much of the suffering in chronic pain comes from:

• Fighting against pain
• Avoiding activities due to pain
• Getting caught up in negative thoughts about pain
• Putting life on hold until pain improves

ACT suggests that while pain may not be controllable, our response to pain is. By changing our relationship to pain, we can reduce suffering and live more fully.

The Six Core Processes

ACT builds psychological flexibility through six interconnected processes:²

1. Acceptance

Making room for pain and difficult feelings:

• Allowing pain to be present without fighting it
• Observing sensations with openness and curiosity
• Reducing the "struggle layer" of suffering
• Not the same as passive resignation

2. Cognitive Defusion

Changing your relationship to thoughts:

• Recognizing thoughts are just thoughts, not facts
• Creating distance from unhelpful thoughts
• Reducing the power of negative thinking
• Example: Instead of "I can't do anything," notice "I'm having the thought that I can't do anything"

3. Present Moment Awareness

Being fully engaged with the here and now:

• Mindful attention to current experience
• Not dwelling on past or worrying about future
• Noticing what is actually happening right now
• Connection with the present moment

4. Self-as-Context

Recognizing you are more than your pain:

• You are the observer of your experiences, not the experiences themselves
• Pain and thoughts are passing experiences
• A stable sense of self that pain cannot damage
• "I am a person experiencing pain" rather than "I am a pain patient"

5. Values

Clarifying what matters most to you:

• Identifying your deepest values (family, creativity, helping others, etc.)
• Values are directions, not destinations
• Provides motivation and meaning
• Guides decisions about how to live

6. Committed Action

Taking action aligned with values despite pain:

• Setting goals based on values
• Taking steps toward meaningful life
• Willingness to experience discomfort in service of values
• Building patterns of effective action

ACT vs. Traditional CBT

While both are effective for chronic pain, they differ in approach:³

Traditional CBT

• Focuses on changing unhelpful thoughts
• Aims to reduce negative thinking
• Challenges and restructures cognitions
• Goals often include pain reduction

ACT

• Focuses on changing relationship to thoughts
• Accepts thoughts without fighting them
• Creates distance from thoughts rather than changing them
• Goals focus on valued living, not pain control

Both approaches have research support. Some people respond better to one than the other, and many therapists use elements of both.

Research Evidence

ACT has solid research support for chronic pain:^4,5

What Research Shows

• Reduces pain interference and disability
• Improves quality of life and functioning
• Reduces depression and anxiety
• Increases psychological flexibility
• Effects maintained at follow-up

Conditions Studied

• Chronic low back pain
• Fibromyalgia
• Chronic widespread pain
• Mixed chronic pain conditions
• Headaches

Delivery Formats

• Individual therapy
• Group programs
• Online/app-based programs
• Self-help books and workbooks

ACT Exercises

Simple techniques to start practicing ACT principles:

The Struggle Switch

Imagine you have a "struggle switch" inside:

• When ON, you fight against pain and negative feelings
• This fighting creates additional suffering
• Turning it OFF means allowing pain to be present
• Energy goes toward values instead of struggle

Leaves on a Stream

1. Close your eyes and imagine sitting beside a stream
2. Leaves are floating by on the water
3. As thoughts arise, place each one on a leaf
4. Watch the leaf float downstream
5. When mind wanders, gently return to watching leaves
6. Practice for 5-10 minutes

This exercise creates distance from thoughts without fighting them.

"I'm Having the Thought That..."

When you notice an unhelpful thought:

• Instead of: "I can't cope with this pain"
• Say: "I'm having the thought that I can't cope with this pain"
• Then add: "I notice I'm having the thought that I can't cope with this pain"
• This creates distance and reduces the thought's power

Values Clarification

Reflect on these questions:

• What kind of person do you want to be?
• What matters most to you in life?
• If pain were less of a barrier, what would you do more of?
• What do you want your life to stand for?

Common values domains: family, relationships, work, health, growth, creativity, community, spirituality.

Willingness

Practice being willing to experience discomfort:

• Choose a valued activity you have been avoiding
• Notice the urge to avoid due to potential pain
• Ask: "Am I willing to have this discomfort in order to do what matters?"
• If yes, take action while making room for whatever shows up

Applying ACT to Daily Life

When Pain Increases

• Notice the pain with curiosity rather than alarm
• Allow it to be present without fighting
• Observe your thoughts about the pain
• Ask: What value-aligned action can I take right now?

When Struggling with Activity

• Connect with why this activity matters (the value behind it)
• Be willing to have pain as you engage
• Notice thoughts urging you to stop, and continue anyway
• Celebrate that you are living by your values

Setting Values-Based Goals

1. Identify an important value
2. Choose a specific action that reflects this value
3. Make it achievable (small steps)
4. Note the willingness required
5. Take action and notice the experience

Finding ACT Treatment

Individual Therapy

• Look for therapists specifically trained in ACT
• Association for Contextual Behavioral Science has a therapist directory
• Ask about experience with chronic pain
• Sessions typically weekly, 8-16 sessions or ongoing

Group Programs

• Pain clinics may offer ACT-based groups
• Can be effective and more affordable
• Benefit from peer support

Self-Help Resources

• Living Beyond Your Pain by JoAnne Dahl and Tobias Lundgren
• The Happiness Trap by Russ Harris (general ACT)
• Get Out of Your Mind and Into Your Life by Steven Hayes
• Online courses and apps

Common Questions

Does acceptance mean I should stop treating my pain?

No. ACT does not discourage medical treatment. Acceptance means not putting your life on hold while fighting pain. You can accept pain AND take appropriate medical action.

Won't accepting pain make it worse?

Research shows the opposite—acceptance often reduces pain intensity over time, likely because less struggle means less stress, which reduces the nervous system's alarm state.

Is ACT saying the pain is in my head?

Absolutely not. ACT recognizes pain is real. It addresses the psychological suffering that accompanies pain, which is also real and important to address.

How long until I see results?

Some people notice shifts quickly; for others it takes longer. Typically, 8-12 weeks of practice shows meaningful improvement. Like any skill, benefits increase with practice.

References