The Six Core Processes of Acceptance and Commitment Therapy (ACT) and How They Improve Physical Therapy Outcomes

Acceptance and Commitment Therapy (ACT) is rooted in psychological flexibility, which is the ability to contact the present moment more fully as a conscious human being, and to change or persist in behavior when doing so serves valued ends. Psychological flexibility can be broken down into the 6 core processes of ACT. These processes can be utilized by physical therapists in treating patients with chronic pain and to promote positive behavior change. Doing so can increase a patient’s function and allow them to return to living their life in a meaningful way.



Values should be established early in treatment, as they will help to guide future care and goal setting.  Physical therapists are very familiar with creating goals for their patients, so it is important to note that values are not the same as goals. Goals are in the future; they have an end date. On the other hand, values are in the present and never have an ending. While they are two separate entities, a patient’s personally held values can be utilized to develop goals that bring them closer to that value. For example, “Pt will be able to lift 20lbs with proper biomechanics” could be a goal for a patient who is a parent and values spending time with their young children and wants to be able to lift them. Values can fall into one of ten domains, including:

2. Health
3. Community
4. Social connections
5. Leisure
6. Parenting
7. Marriage/partner/intimacy
8. Work/education
9. Spirituality
10. Professional development. 

Values are crucial because they help to increase compliance in terms of health-related behavior (1,2). They will also help to guide committed action, which will be discussed later.



Defusion is a term unique to ACT and is the ability to observe one’s thoughts from an alternative perspective rather than getting caught up in them. The goal of defusion is to change the influence of verbal events on behavioral processes (3), specifically to lessen their negative impact. Defusion is beneficial when patients seem to be stuck within their own thoughts, rather than attempting to look at them from another perspective. Patients with chronic pain may have thoughts such as “I can’t do that because of my bad back”, which can easily lead to a downward spiral of continued suffering and missing out on activities they enjoy and value. One simple way of practicing defusion is simply to encourage patients to notice their thoughts and acknowledge that they are just that; thoughts. They are not necessarily true and may even sound silly when a patient says them out loud.


Acceptance allows patients to increase their willingness and experience unpleasant sensations and (possibility) pain, instead of constantly trying to avoid it. For example, a patient with chronic low back pain may have anxiety about potential pain when performing certain movements. There is nothing wrong with this feeling or these thoughts but avoiding all movements as a result can have negative impacts on a patient’s quality of life and cause them to miss out on things they value. Using cognitive defusion techniques, a patient should recognize that they are having these thoughts and that they are normal, but it should not cause them to avoid participation in activities that are important to them. Acceptance includes allowing unpleasant emotions, sensations, and experiences to occur, which has been shown to increase task persistence (4). To put it simply, patients should be encouraged to allow unpleasant sensations to be present if it allows them to move closer to their established personal values. Let it be.



Mindfulness is a key component of ACT and helps to bring about present moment awareness. This allows a patient to focus on the “here and now” while noticing their thoughts as well as their surroundings. It frees someone from constantly ruminating on the past or potential future and centers their focus on the present. Most patients with chronic pain will likely have a history of prior experiences relating to their back pain in addition to possible fear and anxiety about what the future may hold in terms of their condition. Patients with chronic pain have likely been through a lot; including differing opinions from healthcare professionals, medications, prior physical therapy treatment, imaging, injections, surgeries, and many more. Using short mindfulness ACT techniques to bring them to the present can help promote acceptance and awareness of experiences.

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Closely related to present moment awareness is self as context, which allows an individual to access their “observer self”. This process is best explored following several sessions on defusion, acceptance, and present moment awareness. Once a patient has experience noticing their own thoughts and sensations, self as context allows them to notice that there is a part of themselves that does the noticing. In doing so they become less attached to their conceptualized self, which in turn allows them to choose actions that are in line with their values. Emotions, thoughts, and sensations no longer control actions, rather the patient uses values to guide their actions.


In order to achieve behavior change, a patient must take committed actions that bring them closer to their personally established values. Committed action helps to expand a patient’s values into larger and larger patterns of activity (3). By embracing the previously mentioned core processes, patients are able to move towards their values even if pain or fear is “along for the ride”. This allows patients to participate in activities that are meaningful to them instead of missing out. This can help increase a patient’s quality of life, even though pain may still be present. This is where goal writing in ACT can come into play and reflect back onto the patient’s values.

Shelby McClure is a third year Doctorate of Physical Therapy student at Augusta University in Augusta, Georgia and will be graduating in May of 2020. She completed her undergraduate education at Auburn University in Alabama where she earned a B.S. in Fitness, Conditioning, and Performance in addition to a B.S. in Nutrition and Wellness.

Shelby began dancing at a young age which helped to shape her initial interest in health. During college, she worked as a dance instructor as well as a group fitness instructor, which eventually led her to pursue a career in physical therapy. 

Throughout her time at Augusta University and subsequent clinical rotations, Shelby realized her passion for pain science and psychologically informed physical therapy. Shelby is currently completing a 4-week elective with the Integrative Pain Science Institute prior to her graduation.

Shelby is from the Atlanta, Georgia area where she currently resides with her husband of 2 years.

To learn more about Shelby, visit her LinkedIn.


  1. Chase, J. A., Houmanfar, R., Hayes, S. C., Ward, T. A., Vilardaga, J. P., and Follette, V. M. (2013). Values are not just goals: online ACT-based values training adds to goal-setting in improving undergraduate college student performance. J. Contextual Behav. Sci. 2, 79–84. doi: 10.1016/j.jcbs.2013.08.002
  2. Jackson, M. L., Williams, W. L., Hayes, S. C., Humphreys, T., Gauthier, B., and Westwood, R. (2016). Whatever gets your heart pumping: the impact of implicitly selected reinforcer-focused statements on exercise intensity.J. Contextual Behav. Sci. 5, 48–57. doi: 10.1016/j.jcbs.2015.11.002
  3. Zhang CQ, Leeming E, Smith P, Chung PK, Hagger MS, Hayes SC. Acceptance and Commitment Therapy for Health Behavior Change: A Contextually-Driven Approach. Front Psychol. 2018;8:2350. Published 2018 Jan 11. doi:10.3389/fpsyg.2017.02350
  4. Levin, M., Hildebrant, M., Lillis, J., and Hayes, S. C. (2012). The impact of treatment components suggested by the psychological flexibility model: a meta-analysis of laboratory-based component studies. Behav. Ther. 43, 741–756. doi: 10.1016/j. beth.2012.05.003

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