Acceptance and
Commitment Therapy.
What if our relationship to difficult internal experience matters as much as removing it? ACT asks people to change how they relate to difficult thoughts, feelings and sensations, rather than trying to eliminate them, and to build a life around what actually matters to them. Disability complicates this in one crucial way: not everything ACT calls “difficult internal experience” is internal. Some of it is an inaccessible building, an unjust benefits system, or a diagnosis nobody has taken seriously.
What it pays attention to: a person’s relationship to their thoughts and feelings, not just their content, alongside whether their behaviour is actually moving toward what matters to them.
What disability asks it to reconsider: acceptance work can slide, without anyone intending it, into asking a person to accept something that should actually change. Pain may need accepting. An inaccessible service does not.
The proposition this page holds: ACT can help someone build a workable relationship with what genuinely cannot change. It should never be used to make someone more comfortable with what should be changed instead.
Part 1 of 9 · Short explanation
For therapists: start here
Five practice points for ACT, drawn from this section. About two minutes.
- Ask what needs accepting, what can be changed, and what deserves resisting. Read more
- Tell experiential avoidance apart from real access barriers. Read more
- Defuse from thoughts about pain, not from the pain itself. Read more
- Size committed action to today’s actual capacity. Read more
- Check whether a values conflict is really a resource conflict. Read more
Try in your next session: when acceptance comes up, ask together: “Is this unchangeable, or currently unaddressed?”
Watch for: acceptance being asked for instead of advocacy. More
Before the theory, the experience.
I keep being told to accept my diagnosis
There’s nothing wrong with how I actually feel about it. I don’t need to feel differently about it to move forward.
My pain isn’t a thought I can defuse from
It’s a sensation with a physical cause. No amount of noticing it “as just a thought” changes that.
I was told to “make room” for how people treat me
Acceptance of discomfort is one thing. Being asked to tolerate discrimination is another.
Values work assumes I can choose how my life looks
Some of what shapes my life isn’t a values conflict. It’s a lack of support, money, or access.
I don’t need mindfulness, I need accessible transport
Being more present with my situation doesn’t change the situation.
Committed action assumes energy I don’t have
Being told to act on my values on a day I’m already at capacity just adds guilt to exhaustion.
Where would you like to begin?
31 pages is a lot to face as one long list. Start wherever your own question actually lives — pages marked TRY IT are exercises and worksheets rather than articles to read.
Acceptance, Reality & Uncertainty
What does acceptance actually mean?
Values, Action & Capacity
How do I move toward what matters when energy, access and opportunity aren’t unlimited?
Thoughts, Fear & Avoidance
What belongs to the mind, and what belongs to reality?
Identity, Body & Internalised Ableism
How do I relate to myself and my body without either rejecting or romanticising disability?
Particular Disability Experiences
What changes when ACT meets a specific lived context?
Part 2 of 9 · What it pays attention to
Psychological flexibility, not symptom removal.
ACT’s core target is psychological flexibility: the capacity to stay in contact with the present moment and change or persist in behaviour in the service of chosen values, even when difficult thoughts and feelings are present. Six interlocking processes are usually described together as the “hexaflex.”
Defusion
Noticing thoughts as thoughts, rather than facts that must be obeyed or believed.
Acceptance
Making room for difficult internal experience rather than struggling against it.
Present moment
Contacting what’s actually happening now, rather than the past or an imagined future.
Self-as-context
A stable sense of self that can observe experience, rather than being defined by any single thought or feeling.
Values
Chosen life directions, distinct from goals, that give action its meaning.
Committed action
Building larger and larger patterns of behaviour in the service of those values.
Psychological inflexibility, and its limits.
ACT locates much human suffering in psychological inflexibility: rigid attempts to avoid or control difficult internal experience, becoming entangled with the literal content of thoughts, and behaviour that drifts away from what actually matters to someone. Change, on this account, comes from loosening those rigid patterns and reconnecting behaviour to freely chosen values, rather than from disputing the content of thoughts directly. This model was built to explain suffering that comes from a person’s relationship to their own mind. It was not built to explain suffering that comes from an inaccessible building, a disbelieving clinician, or a benefits system designed to exhaust people into giving up — and disability-informed ACT has to hold both possibilities, not assume the first by default.
Part 3 of 9 · What sessions might involve
What might a session actually involve?
A session may involve identifying a thought that’s become sticky or controlling, and practising ways of holding it more lightly, saying “I’m having the thought that…” before a difficult belief, for instance. It may involve values clarification, working out what actually matters to someone, separate from what they think they should want. It may involve committed action, breaking a values-aligned goal into a step that’s genuinely achievable given today’s capacity.
ACT does not require imagining metaphors that assume a body that moves easily, closing your eyes if that doesn’t feel safe, or treating every difficult feeling as something to accept rather than to change.
Try this, if it feels manageable.
Think of a thought that’s been repeating itself today, ideally not the most distressing one you have. Say it to yourself as: “I’m having the thought that [thought].” Then notice: did saying it that way change anything about how true, urgent or heavy it felt? There’s no correct answer. If the thought is actually an accurate read of a real, unresolved problem, the goal isn’t to make it feel lighter — it’s to notice the difference between a thought and a fact worth acting on.
Part 4 of 9 · Disability-related considerations
Accept — Change — Resist.
ACT’s word “acceptance” becomes dangerous applied indiscriminately. Disability-informed ACT needs a second question sitting right alongside it: what needs accepting, what can be changed, and what deserves resisting? Psychological flexibility can include all three — acceptance, adaptation, and protest.
Accept
Realities currently outside voluntary control.
- Pain
- A diagnosis
- Permanent impairment
- A changed body
- What happened in the past
- Other people’s thoughts
- Uncertainty
- Grief, fear, and the emotions that arise
Change
What can genuinely be influenced — including finding a different route to the same thing while the underlying reality stays fixed.
- How I speak to myself
- How I arrange support
- My boundaries
- My environment and routines
- How I communicate access needs
- How I spend limited energy, or adapt how a valued activity happens
- Which relationships I invest in
- What action I take toward what matters
Resist
What should not simply be accepted.
- Discrimination
- Inaccessible buildings
- Medical neglect
- Being infantilised
- Abusive care, exclusion
- Unreasonable institutional barriers
- Denial of reasonable accommodations
- The assumption that psychological adjustment should compensate for structural injustice
The three columns aren’t a diagnostic sequence to work through in order. The same situation often has pieces in all three at once, and sorting which piece belongs where is itself the clinical work, done with the person. Change sometimes shows up as adaptation: a wheelchair user can’t change the stairs, may resist the inaccessibility, and can also, while waiting for either, find a different venue.
When disability enters each process.
The hexaflex is genuinely useful. It becomes inaccurate the moment any of its six processes is used to smooth over something that was never psychological in the first place. Each one has its own full treatment elsewhere in this section — this is the short version.
Defusion Read more →
“I’m having the thought that I’m in pain” can help with catastrophic thinking about pain. It cannot defuse the pain itself, a sensation, not a thought. The question: is this defusing from a thought about a sensation, or quietly from the sensation itself?
Present moment Read more →
Contacting the present moment can reduce anxious rumination, but it doesn’t have to mean going inward — for a body that isn’t safe to attend to closely, the room itself is just as genuine a place to arrive. The question: internal noise to notice, or an external problem that actually needs addressing?
Self-as-context Read more →
Powerful for someone whose identity has been reduced to a diagnosis — not only the pain, not only the label. The question: is “you are more than your body” widening someone’s sense of self, or quietly dismissing a real, current bodily need?
Acceptance
The sharpest disability critique sits here. Acceptance can help someone stop fighting a genuinely unchangeable fact and build a life around it. It can also become a way of asking someone to make peace with a failure of the world, not a fact of their body. The question: is this genuinely unchangeable, or is acceptance being asked for instead of advocacy?
Values Read more →
Values clarification assumes an open field of choice. Disability, poverty, and inadequate support can narrow which values are practically pursuable, not because the values changed, but because the resources to act on them did. The question: is a values conflict actually a resource conflict in disguise?
Committed action Read more →
Committed action assumes available energy for the next step. For fluctuating capacity, that assumption itself needs checking before any step is set. The question: achievable given today’s actual capacity, or does it demand more and read the shortfall as low commitment?
Acceptance is not resignation. And not everything a disabled person is asked to accept is actually theirs to accept.
Who decides what needs accepting?
ACT gives a therapist real interpretive power over which struggles get named as “acceptance work” and which get named as a problem to solve. A therapist doesn’t get to decide, on the client’s behalf, that something is simply a fact of life to make peace with. That decision belongs, first, to the person living it, and second, to an honest look at whether the thing in question is actually fixed, or just currently unaddressed.
Part 5 of 9 · Possible adaptations
Not a more accepting person. Greater discernment about what’s actually theirs to hold.
Change might mean
- Noticing a sticky thought without immediately obeying it
- Making peace with a genuinely unchangeable fact of the body
- Naming which struggles are actually resource or access problems
- Taking a values-aligned step sized to today’s real capacity
- Feeling anger at injustice without needing to defuse from it
- Having more choice about which battles to spend energy on
Change does not have to mean
- Feeling calmer about discrimination
- Accepting an inaccessible service instead of challenging it
- Becoming more tolerant of pain that has an addressable cause
- Pursuing every value regardless of actual, current capacity
- Letting go of anger that’s actually accurate information
- Being at peace with everything, all the time
The goal is not a more accepting person. It is a person who knows the difference between what’s genuinely theirs to accept and what was never theirs to carry.
Part 7 of 9 · Evidence and limitations
Neither oversold, nor dismissed.
A widely cited 2015 meta-analysis (A-Tjak et al.) of 39 randomised controlled trials with 1,821 patients found ACT more effective than waiting list, psychological placebo and treatment as usual, with no significant difference from established treatments such as CBT. The trials covered anxiety, depression, addiction and physical health problems.
Chronic pain is one of the most studied areas for ACT, and one where the acceptance model fits the clinical reality closely. Reviews find improvements in functioning, but a 2020 Cochrane review rated the evidence for ACT in chronic pain as very low certainty. More on ACT and Chronic Pain: What the Evidence Actually Shows.
Evidence that ACT helps people live well alongside a genuinely fixed reality does not establish that acceptance is the right response to a reality that is actually unjust or changeable, such as discrimination or inadequate support.
A critical reading, not a devotional one
ACT was developed by Steven C. Hayes, along with Kirk Strosahl and Kelly Wilson, building on relational frame theory and a functional-contextual philosophy of science, and has since been extended by clinicians including Robyn Walser, Russ Harris and JoAnne Dahl into specific clinical populations, including chronic pain.
The aim here is the same question ACT itself invites: is a given application of acceptance actually workable for this person’s real situation, or has it quietly become another way of asking someone to adapt to circumstances that were never fixed in the first place? The disability critique does not weaken ACT. It helps apply ACT more precisely — and the pages throughout this section exist to show where it holds and where it needs a second look, not to argue against using it.
Part 8 of 9 · Questions to ask a therapist
Questions to ask an ACT therapist
Practice varies between therapists. These questions can help you find out how a particular therapist works, before you start or at any point. A good therapist will welcome them.
- How do we decide together what to accept and what to try to change?
- Would acceptance ever be applied to things that should change, like barriers or discrimination?
- How do you adapt mindfulness or other exercises for pain, fatigue or sensory needs?
- How do values work in your approach if my options are limited by access?
- How will we review whether it’s helping?
More general questions: Questions to Ask Before You Start. These questions are this site’s own.
Questions worth carrying.
Am I naming this as “acceptance work” because it genuinely is, or because it’s easier than helping this person challenge something structural? Have I checked whether a values conflict is actually a resource conflict? Does this committed-action step assume a capacity this person doesn’t currently have? Would I still call this “psychological inflexibility” if I knew the full context of what this person is up against?
The exercises and metaphors used across ACT are invitations, not universal prescriptions. Some assume visual imagination, sustained attention, closed eyes, or stillness that not everyone can or wants to offer. Any exercise should be genuinely optional, with a workable alternative always available.
Part 9 of 9 · Related resources and references
Accept, change, resist
ACT asks what you can make room for and what you can act on. A disability lens adds a third question: what deserves resistance? Take one situation.
- The situation. What’s happening?
- Accept: what can’t change right now? Feelings, sensations or facts about my body I can make room for.
- Change: what is within my reach? An action, a request, a different way of doing it.
- Resist: what is unjust or shouldn’t be accepted? A barrier, a policy, the way I’m being treated.
- Which value does this serve? Connection, dignity, creativity, fairness, rest?
- One small step, within the energy I actually have this week.
Accepting reality is not the same as accepting injustice. More: ACT vs Resignation. To keep a copy, use your browser’s print option and choose “Save as PDF”.
Acceptance versus resignation
To me, acceptance involves acknowledging the reality of a situation without necessarily giving up on change. Living with a disability highlights an important distinction: accepting a physical reality does not mean accepting discrimination, inaccessible environments or unnecessary limitations.
Casey Donaghey is the psychotherapist behind this site and lives with cerebral palsy.
What disabled people have said
Susan Wendell, on control and limits
Wendell, a philosopher who became ill with ME/CFS, argued that Western culture’s belief that we can control our bodies leaves little room to imagine living well with illness or limitation. Disabled people’s knowledge of the body, she wrote, is missing from much of what we think we know about bodies.
Norman Kunc and Emma Van der Klift, on the right to be disabled
Kunc, who has cerebral palsy, and Van der Klift write that disabled people have a right to be disabled, without being required to become less disabled first. They describe how benevolence and low expectations can quietly turn friendship and support into control.
Sources
- Wendell, S. (1996). The Rejected Body: Feminist Philosophical Reflections on Disability. Routledge.
- Van der Klift, E., & Kunc, N. (2019). Being Realistic Isn’t Realistic: Collected Essays on Disability, Identity, Inclusion and Innovation.
Summaries are this site’s own wording. Please read the originals.
The statements under “You might recognise this” are composite voices drawn from common experiences, not words from individual people. Any case or dialogue on this page is a fictional teaching example.
Evidence & sources
Sources checked in October 2026, using targeted searches rather than a systematic review. “We have not located” means our searches did not find it.
Established concept
Hayes, S. C., Strosahl, K. D. & Wilson, K. G. (1999), Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change. New York: Guilford Press.
Established concept
The six processes (“hexaflex”): Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A. & Lillis, J. (2006), “Acceptance and commitment therapy: Model, processes and outcomes”, Behaviour Research and Therapy, 44(1), 1–25.
Research finding
A-Tjak, J. G. L. et al. (2015), “A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems”, Psychotherapy and Psychosomatics, 84(1), 30–36. doi:10.1159/000365764.
Research finding
Williams, A. C. de C. et al. (2020), Cochrane review of psychological therapies for chronic pain, CD007407. doi:10.1002/14651858.CD007407.pub4.
Our framework
The Accept, Change, Resist reframe, and the disability reading of each of the six processes, are this site’s synthesis.
Not yet known
Our targeted searches did not find trials of ACT designed around particular disabled groups beyond chronic pain, or trials testing the Accept, Change, Resist distinction.
Last reviewed: October 2026.
How to cite this page: Donaghey, C. (2026). Acceptance and Commitment Therapy. Disability in Psychotherapy. Available at: https://disabilityinpsychotherapy.online/what-is-psychotherapy/acceptance-and-commitment-therapy/ (Accessed: [date]).
Shared under CC BY-NC 4.0, with extra permissions for teaching, supervision and therapy. Credit the site. See Reusing This Material.