Acceptance and commitment therapy for substance use

Acceptance and commitment therapy, usually said as one word ("act"), is a form of talking therapy that does not try to eliminate cravings or uncomfortable thoughts. It aims to change a person's relationship with them. Research on ACT for substance use is growing, and the results so far are promising in some respects and unsettled in others.

What ACT is

The APA Dictionary of Psychology describes ACT as a form of cognitive behavior therapy built on the idea that ineffective attempts to control thoughts and feelings can themselves cause problem behaviors. The therapy helps people drop those control strategies and instead accept difficult thoughts, which it treats as words put together in a certain way, and difficult feelings as part of a worthwhile life. It draws on relational frame theory, developed by the psychologist Steven Hayes, and has been applied to depression, anxiety, stress and substance use.

A 2020 review in the Journal of Clinical Medicine Research sums up its use in substance use disorders: people are guided to accept the urges and symptoms linked to substance use, then to use psychological flexibility and values-based work to act differently.

How ACT works in outline

That review lists six processes, which are the working parts of ACT:

• Acceptance: allowing urges, emotions and sensations to be present without a fight.
• Defusion: stepping back from thoughts such as "I can't cope without using" and seeing them as thoughts, not commands.
• Flexible attention to the present moment: noticing what is happening now instead of being pulled into worry or craving.
• Self-as-context: observing experiences from a steadier perspective, without being defined by them.
• Values: clarifying what matters, such as family, work or health.
• Committed action: taking concrete steps in line with those values, even when discomfort shows up.

Together these build what ACT calls psychological flexibility, described in the review as the ability to meet the present moment and adjust one's actions toward a chosen aim. The review contrasts this with cognitive behavioral therapy (CBT), in which people more often try to avoid or replace urges with healthier alternatives. The two overlap, and the APA Dictionary itself classes ACT as a form of CBT.

What sessions can look like

The sources reviewed for this page do not give a standard session script, and formats differ between programs. Based on how the approach is described, sessions may include discussion of past attempts to control cravings, exercises for noticing urges and thoughts without acting on them, time spent naming personal values, and agreed actions between sessions. A clinician can explain the format and length, and whether it is delivered individually or in a group.

What the research says

A 2020 literature review of 22 studies (Osaji and colleagues) found that most showed reductions in substance use right after treatment and at follow-up, whether ACT was used alone or alongside other care. Comparisons were mixed. In one study of 50 women in a Spanish prison, drug use fell in 43.8 percent of those given ACT and 26.7 percent of those given CBT after six months. But in a residential treatment study, an ACT and mindfulness group did not differ significantly from usual treatment, and a study of people on methadone found no significant difference from regular drug counseling.

A 2024 systematic review and meta-analysis in the Journal of Contextual Behavioral Science included 28 studies in its review and 22 in its meta-analysis, comparing ACT with other active treatments. Completion rates did not differ. ACT increased the odds of abstinence at the end of treatment and at short-term follow-up, but not in the long term. ACT groups also tended to improve more on psychological flexibility, though the authors say further studies are needed to clarify whether raising flexibility drives the changes in addictive behavior. The page available to us did not rate the overall certainty of the evidence.

The 2020 review lists its own limits: small samples, no blinding, and abstinence reported by participants themselves. Many studies also followed people for a short time only.

Limits and who it may not suit

• Results beyond the short term are unclear, since the 2024 meta-analysis did not find a long-term advantage in abstinence.
• The studies reviewed compared ACT with other psychological treatments. They do not show that it can stand in for medication where medication is part of care; see medications used in treatment.
• Other approaches take a more skills-based route to avoiding triggers, as in relapse prevention, or a motivation-focused route such as motivational interviewing.
• The sources reviewed here do not say who should avoid ACT, so timing and fit are questions for a clinician.

Related approaches include dialectical behavior therapy, which also pairs acceptance with change, and mindfulness-based approaches.

Questions to ask a clinician

• Is this program based on ACT as published, and what training does the therapist have in it?
• How would ACT fit with any medication or other treatment I am receiving?
• What would we aim for, and how will we know within a few weeks whether it is helping?
• Is it offered individually, in a group, or both, and for how many sessions?
• What happens if I have a lapse during the program?