Acceptance and commitment therapy (ACT)

At a glance

Compared with waiting

Better than waiting in a US trial of 87 people.

Compared with other treatments

About the same as CBT in that trial, on self-reports, clinician ratings and a speech test.

What it takes

12 sessions with a therapist in the main trial.

What it is

Acceptance and commitment therapy (ACT, said like the word “act”) is a talking therapy. It does not try to make anxious thoughts go away. It helps you stop letting them decide what you do.

In ACT you work on three things:

• Making room for feelings. You practise letting anxiety be there without fighting it, hiding it or running from it. Fighting anxiety often makes it louder.
• Stepping back from thoughts. Defusion: seeing a thought like “they think I’m boring” as a thought, not a fact. One exercise is saying “I’m having the thought that…” before it.
• Acting on your values. You decide what matters to you, such as friendship, a career or a hobby. Then you take steps toward it, with the anxiety along for the ride.

That last part means ACT still includes facing feared situations. The reason is different from CBT: you go to the party because friendship matters to you, not to prove the fear wrong.

Why people choose it

• You don’t have to win the argument with your thoughts. Some people find CBT’s “check the evidence” approach tiring. ACT asks a different question: is this thought helpful?
• It fits people who have fought anxiety for years. If you are worn out from trying to feel calm before you act, ACT offers another way in.
• It looks at your whole life, not only the symptoms.

What the evidence shows

• One good trial found it equal to CBT. In a US trial of 87 people, 12 sessions of ACT and 12 sessions of CBT both helped more than waiting. There were no differences between them on self-reports, clinician ratings or a speech test. People who also had depression did less well with either therapy.
• Far fewer trials than CBT. ACT has much less evidence for social anxiety than CBT. In a study that combined 101 trials, individual CBT made for social anxiety had the largest effect of any treatment. That is why we rate ACT lower.
• Related approaches give mixed results. Mindfulness, which overlaps with ACT, helped more than no treatment but did a little less well than CBT when trials were combined. See mindfulness-based therapy.

What the trials have not answered

• Whether ACT works as well as cognitive therapy made for social anxiety, the best-tested therapy. No trial has compared them.
• How long the benefits last compared with CBT.

How to get it

Many therapists offer ACT, but few specialize in social anxiety. Ask: “Do you use ACT for social anxiety, and will we work on facing situations I avoid?” If a therapist offers only acceptance exercises and no steps into real situations, that is a weaker version of the approach.

ACT is a reasonable choice if CBT has not suited you, or if it is what your local service offers. If you can choose freely, CBT made for social anxiety has more evidence behind it.