ACT for anxiety disorders review paper

Key summary

Acceptance and commitment therapy (ACT) has emerged as an effective approach for treating anxiety disorders. The findings suggest that ACT offers a viable alternative to traditional cognitive behavioural therapy (CBT), with a unique focus on psychological flexibility, values, and experiential acceptance. Additionally, ACT’s emphasis on values-guided behavioural exposure and mindfulness provides clinicians with tools to help clients engage meaningfully with anxiety-provoking situations. Clinical recommendations include prioritising values-based exposure, integrating acceptance strategies, and fostering psychological flexibility to help clients align their actions with their values.

Key findings

Theoretical foundation of ACT for anxiety disorders

• Anxiety disorders are characterised by rigid experiential avoidance, which involves avoiding or suppressing anxiety-related thoughts, emotions, and sensations.
• ACT addresses this rigidity by fostering psychological flexibility, which allows individuals to choose adaptive responses based on the specific context and their personal values.
• The six core processes of ACT (collectively known as the “hexaflex”)—present moment awareness, acceptance, self-as-context, cognitive defusion, values, and committed action—aim to transform avoidance behaviours into flexible, values-based actions.

Unique aspects of ACT for anxiety disorders

1. Values-guided behavioural exposure:
   • Unlike traditional exposure therapy, which focuses on fear habituation or inhibitory learning, ACT frames exposure as an opportunity to engage in activities aligned with personal values.
   • For example, a parent with panic disorder may attend their child’s performance, despite anxiety, by focusing on their values as a loving and supportive parent.
2. Integration of mindfulness and acceptance:
   • ACT encourages present moment awareness and acceptance of anxiety-related sensations, thoughts, and emotions, rather than attempting to eliminate them.
   • Techniques such as cognitive defusion help clients relate flexibly to distressing thoughts, viewing them as transient mental events rather than absolute truths.
3. Focus on workability:
   • ACT assesses whether a coping strategy is effective in moving an individual toward their values (workability), rather than whether it reduces anxiety.
   • This approach encourages adaptive behaviours, even in the presence of anxiety, fostering long-term resilience.

Research evidence supporting ACT

• Effectiveness:
  • ACT has been shown to be as effective as CBT in treating anxiety disorders, with evidence from randomised controlled trials for generalised anxiety disorder (GAD), social anxiety disorder (SAD), and mixed anxiety disorders.
  • ACT and CBT generally lead to comparable symptom reductions, though ACT may provide unique benefits in areas such as social behaviour and values alignment.
• Delivery formats:
  • ACT has been effectively delivered through individual and group therapy, self-help books, and online platforms, increasing accessibility for diverse populations.
• Processes of change:
  • Meta-analytic evidence suggests that ACT’s core processes, such as experiential acceptance and mindfulness, are linked to improvements in anxiety symptoms. However, these processes may also play a role in other therapeutic approaches, such as CBT.

Clinical recommendations

Implications for clinicians

1. Focus on values-guided exposure:
   • Clinicians should frame exposure exercises as opportunities for clients to engage in meaningful, values-driven behaviours, rather than solely aiming to reduce anxiety.
   • For example, a client with social anxiety might be encouraged to attend a gathering to connect with loved ones, rather than to “overcome” fear.
2. Encourage acceptance over control:
   • Rather than attempting to eliminate anxiety, clinicians can guide clients to accept anxiety as part of the human experience. Techniques such as mindfulness and acceptance meditations can help clients open up to their sensations and emotions without judgment.
3. Foster psychological flexibility:
   • Clinicians should emphasise the importance of flexibility in responding to anxiety-related thoughts and emotions. This may involve helping clients identify and challenge rigid internal rules, such as “I must avoid all situations that cause anxiety.”
4. Utilise metaphors and experiential exercises:
   • Metaphors such as “passengers on the bus” or “leaves on a stream” can help clients relate to their anxiety in new ways, fostering cognitive defusion and self-as-context.
5. Tailor interventions to client values:
   • Given the diversity of client values, ACT interventions should be personalised to help clients clarify what matters most to them and align their actions with these values, even in the presence of anxiety.

Applications across formats

• ACT’s effectiveness across various delivery methods, including online platforms and self-help books, makes it a versatile and accessible approach. Clinicians should explore these options to make ACT more widely available to clients who may face barriers to traditional therapy.

Conclusion

ACT offers a powerful framework for treating anxiety disorders by helping individuals move beyond rigid avoidance behaviours and toward meaningful, values-driven lives. The evidence highlights ACT’s efficacy across a range of anxiety disorders and its unique ability to foster psychological flexibility. For clinicians, the key takeaway is the importance of integrating values, mindfulness, and acceptance into treatment to help clients navigate anxiety with greater resilience and purpose.

Reference

Arch, J. J., Finkelstein, L. B., & Nealis, M. S. (2025). Acceptance and commitment therapy (ACT) for anxiety disorders. Psychiatric Clinics of North America. https://doi.org/10.1016/j.psc.2025.02.003