Acceptance and Commitment Therapy in Occupational Therapy: A Scoping Review

Review Question

What is the scope of the current literature regarding the use of ACT by occupational therapy practitioners?

Subquestions:

How has ACT been described in occupational therapy evaluation and intervention processes?

Eligibility Criteria

Eligibility criteria were structured using the Population–Concept–Context framework, consistent with JBI guidance and the published protocol.

Population: This scoping review considered sources involving participants of any age and any diagnosis receiving services from occupational therapy practitioners. Occupational therapy services could be delivered independently or as part of an interdisciplinary or multidisciplinary team, provided the occupational therapy practitioner's use of ACT or involvement was explicitly stated or could be identified.

Concept: This scoping review examined current literature describing the use of ACT by occupational therapy practitioners during evaluation and/or intervention. Broader cognitive-behavioral terminology was included in the search strategy to maximize sensitivity; however, sources were only included if ACT was explicitly identified and at least one core ACT process (acceptance, cognitive defusion, present-moment awareness, self-as-context, values, or committed action) was described. No restrictions were placed on intervention format.

Context: This scoping review considered literature from any practice setting or geographic location.

Sources were excluded if they mentioned or recommended ACT as a potential approach for occupational therapy practice but did not contain primary research on occupational therapy practitioners’ use of ACT processes during evaluation or intervention. Sources that discussed ACT conceptually without evidence of implementation or application were also excluded. This decision was made to maintain conceptual clarity and to ensure that the review captured literature describing applied occupational therapy use of ACT rather than theoretical discussion alone.

Types of Sources: This scoping review considered quantitative, qualitative, and mixed-methods studies, as well as relevant gray literature. There was no restriction on publication language. Studies published from 1982 onward were eligible, reflecting the year ACT was first introduced (Hayes & King, 2024).

Search Strategy

A comprehensive three-step search strategy was implemented. An initial search of PubMed and Embase was conducted with a health sciences librarian to identify relevant keywords and index terms. These terms informed the development of database-specific search strategies. The PubMed search strategy was peer-reviewed by another librarian using the Peer Review of Electronic Search Strategies (PRESS) guidelines (McGowan et al., 2016). The final search was conducted across PubMed, Embase (Ovid), Scopus, CINAHL (EBSCOhost), PsycINFO (EBSCOhost), OTSeeker, OTDBase, SciELO, ProQuest Dissertations and Theses Global, MedNar, and Google Scholar. Consistent with the protocol, only the first 1000 Google Scholar records were screened. See Rider and LaVerdure (2025) for the complete search strategy.

Study Selection

Database searches were completed on April 30, 2025, and all records were imported into Covidence (Veritas Health Innovation) and duplicates removed. Two reviewers independently screened titles and abstracts. Full-text screening was also completed independently by two reviewers, with reasons for exclusion documented. Disagreements were resolved through discussion or a third reviewer. The selection process is reported using a PRISMA-ScR flow diagram in Figure 1 (Tricco et al., 2018).

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Figure 1.

PRISMA flow diagram.

Data Extraction

Data were extracted independently by two reviewers using a customized extraction tool adapted from the JBI System for the Unified Management, Assessment, and Review of Information (JBI SUMARI). The tool was pilot tested and refined iteratively (Rider & LaVerdure, 2025).

Extracted data included study characteristics, context and setting, participant descriptions, ACT use in evaluation and intervention, ACT principles and strategies, client concerns addressed, reported outcomes, and interdisciplinary involvement.

Data Analysis and Presentation

Data were synthesized using descriptive numerical summaries and narrative synthesis, consistent with JBI recommendations. Frequency counts were used to map patterns in ACT use, client concerns, settings, and outcomes.

Results are presented in a table describing study characteristics and a narrative synthesis organized by the review questions. Formal methodological quality appraisal or risk of bias assessment was not undertaken. Consistent with JBI guidance, the purpose of this scoping review was to map the extent, nature, and characteristics of the evidence rather than assess intervention effectiveness or generate a synthesized clinical recommendation (Peters et al., 2020b).

Terminology was guided by Fisher's occupation-related taxonomy (Fisher, 2013) through data synthesis and interpretation of findings. Within this taxonomy, occupation-centered refers to a profession-specific perspective, with occupation at the center of professional reasoning and practice, and occupation-based refers to using occupation as the foundation, involving direct engagement in meaningful occupation during evaluation or intervention (Fisher, 2013).

Positionality Statement

This review team included both academic and clinical occupational therapists with formal ACT training. JR and JF work primarily in academia, although JR also maintains clinical occupational therapy practice and has formal training in JBI methodology. AL is a full-time clinical occupational therapist. The authors acknowledge that their familiarity with ACT and interest in occupation-centered applications of ACT may have influenced their interpretation of the literature. To support reflexivity and methodological rigor, the review followed established JBI scoping review procedures, included independent review processes, and incorporated regular team discussions on study selection and synthesis.

How Has ACT Been Described in Occupational Therapy and Intervention Processes?

Across studies, the specific role of occupational therapy practitioners in the evaluation process was often not clearly described. While ACT-informed interventions were described, few studies explicitly stated whether occupational therapy practitioners administered ACT-specific outcome measures during evaluation. When ACT-consistent measures were reported, they primarily assessed psychological flexibility and ACT core processes. The most frequently used tools were the Chronic Pain Acceptance Questionnaire (CPAQ; including CPAQ-8 and adolescent versions) and the Acceptance and Action Questionnaire-II (Bond et al., 2011; McCracken et al., 2004). These measures were commonly used in chronic pain and interdisciplinary rehabilitation contexts.

Several studies included measures targeting core ACT processes. These assessments were not occupational-therapy specific, and ACT-related assessments were inconsistently described, often embedded within interdisciplinary research protocols, and placed greater emphasis on measuring psychological flexibility processes rather than occupational outcomes.

ACT was most frequently implemented within interdisciplinary treatment models, in which occupational therapy-specific contributions were not always clearly described. Occupational therapy practitioners served various roles, including developing ACT content, training and supervising other providers in ACT interventions, facilitating ACT-based programs, and delivering ACT-based interventions within an interdisciplinary model. In many studies, ACT was described as part of a team-based rehabilitation or mental health intervention in which occupational therapy practitioners collaborated with psychologists, physicians, nurses, physiotherapists/physical therapists, and social workers (see Table 1). Within these interdisciplinary models, occupational therapy practitioners delivered ACT-based individual and group sessions; however, detailed descriptions of discipline-specific intervention components were inconsistently reported.

Occupational therapy practitioner-led ACT interventions were explicitly described in three studies. These included occupational therapy practitioners providing services in primary care (Koverman et al., 2017), in a home-based setting (Rider & Tay, 2022), and in a survey of occupational therapy practitioners who reported using ACT for clients living with Parkinson's disease (Coleman et al., 2019). Occupational therapy practitioners incorporated ACT into occupation-centered intervention planning, including values-based goal setting, activity engagement planning, behavioral activation, and participation-focused treatment approaches.

Many interventions included strategies to support participants in re-engaging in valued activities despite ongoing symptoms. Mindfulness exercises, experiential activities, metaphors, education, values clarification, goal setting, cognitive defusion techniques, and behavioral activation strategies were commonly described. In family-focused contexts, interventions also targeted psychological flexibility for parents or caregivers (Kemani et al., 2018). Across studies, ACT was described as a process-oriented approach incorporating acceptance, values, clarification, and committed action in relation to engagement in valued activities.

What Client Concerns Have Been Addressed by Occupational Therapy Practitioners’ Use of ACT?

The most frequently reported client concerns addressed were related to pain and its impact on daily life (n = 16). Chronic pain populations included adults and adolescents across practice contexts with persistent pain, pain-related disability, and activity avoidance (see Table 1). Chronic pain-related concerns addressed through ACT included psychological inflexibility, pain acceptance, pain interference, pain-related distress, specific psychosocial concerns (e.g., depression, anxiety, and catastrophizing), occupational participation limitations, and fear- or avoidance-based activity restriction (Daly-Eichenhardt et al., 2016; Finnes et al., 2021; Haage & Tjörnstrand, 2024; Kemani et al., 2018; McCracken et al., 2005, 2015; McCracken & Gutiérrez-Martínez, 2011; McCracken & Jones, 2012; Rider & Tay, 2022; Scott et al., 2016, 2017, 2019; Trompetter et al., 2014; Vowles & McCracken, 2008; Vowles et al., 2007; Yu et al., 2017).

Mental health and psychosocial concerns were also commonly addressed across multiple populations and diagnostic presentations (n = 6). These concerns included depressive symptoms, anxiety, emotional distress, personality disorders, psychotic-spectrum disorders, and broader psychosocial functioning challenges. ACT interventions targeted symptom-related distress, experiential avoidance, psychological flexibility, emotional regulation, quality of life, and participation in meaningful occupations. For example, Clarke et al. (2012) described ACT interventions targeting depressive symptoms, psychiatric distress, and quality of life among adults receiving community mental health services, while Gaudiano et al. (2020a) reported ACT use within an inpatient psychiatric setting to address psychosis, psychiatric symptom severity, wellbeing, functional participation, mindfulness-based skill development, and values-based engagement. Additional studies similarly emphasized psychological flexibility and tolerance of distressing experiences across psychiatric contexts (Cosham, 2013; Moore et al., 2019).

Four studies examined the use of ACT among adolescent/pediatric populations, addressing a range of psychosocial and functional concerns. One example was the “Places You’ll Go” ACT program for adolescent cancer survivors (Clarke et al., 2021), which targeted survivorship priorities including peer connection, sense of community, identity development and meaning-making, distress related to cancer-related uncertainty and worries, disclosure of cancer experiences, and goal-setting linked to valued activity participation. Hayes et al. (2011) reported the use of ACT to address depressive symptoms among adolescents receiving outpatient mental health services. Kemani et al. (2018) examined adolescents participating in a residential pain rehabilitation program, where ACT was used to address decreased functional participation, pain-related cognitive and emotional responses influencing activity engagement, and avoidance behaviors. In an inpatient child psychiatric setting, Makki et al. (2018) described the use of ACT to address psychosocial concerns, including bullying, self-image, habits and addictions, distress tolerance, trauma and loss, health education, and effective communication.

Additional client concerns included neurological and chronic condition-related issues. One cross-sectional survey reported on occupational therapy practitioners’ use of ACT to address psychosocial concerns and participation challenges among individuals with Parkinson's disease (Coleman et al., 2019). Another study examined individuals on long-term sick leave due to pain or mental health disorders using ACT to address concerns about returning to work, psychosocial symptoms, and wellbeing (Finnes et al., 2021). Lastly, one case study described an ACT-informed occupational therapy intervention in primary care to help older adults experiencing complex health-related occupational challenges (Koverman et al., 2017).

Across studies, ACT targeted psychological flexibility, symptom-related distress, participation restrictions, and occupational engagement challenges across diagnostic categories and age groups. All six core ACT processes were represented, reflecting a comprehensive application across client concerns.

In What Settings Have Occupational Therapy Practitioners’ Use of ACT Been Reported?

ACT interventions delivered by occupational therapy practitioners were reported across multiple clinical and community-based settings. The most frequently described setting was residential, inpatient, or tertiary pain rehabilitation programs (n = 12), most of which were conducted in the United Kingdom and involved structured pain management treatment programs (Daly-Eichenhardt et al., 2016; Kemani et al., 2018; McCracken et al., 2005, 2015; McCracken & Gutiérrez-Martínez, 2011; McCracken & Jones, 2012; Scott et al., 2016, 2017, 2019; Vowles & McCracken, 2008; Vowles et al., 2007; Yu et al., 2017). Some studies may have been conducted in the same settings at different times. For example, several were conducted in pain rehabilitation programs in Central London (Daly-Eichenhardt et al., 2016; McCracken et al., 2015; Scott et al., 2016, 2017, 2019; Yu et al., 2017) and Southwest England (McCracken & Gutiérrez-Martínez, 2011; McCracken & Jones, 2012; Vowles et al., 2007; Vowles & McCracken, 2008). While the treatment programs were similar across some of the pain rehabilitation studies, they varied in treatment duration, inclusion and exclusion criteria, and outcome measures. Interdisciplinary rehabilitation programs outside of residential formats were reported in one study (Haage & Tjörnstrand, 2024). Additionally, one implementation study focused on training rehabilitation professionals in ACT for chronic pain across rehabilitation centers (Trompetter et al., 2014).

Inpatient psychiatric settings were reported in three studies (Gaudiano et al., 2020a; Makki et al., 2018; Moore et al., 2019), including both adult and child psychiatric units in the United States. Outpatient mental health services were described in three studies (Clarke et al., 2012; Cosham, 2013; Hayes et al., 2011).

Primary care settings were described in one study (Koverman et al., 2017), and home-based occupational therapy services were reported in one case study (Rider & Tay, 2022). One study described implementation across outpatient clinics, the home, and the workplace (Finnes et al., 2021). A community-based camp survivorship program for adolescents was reported in one study (Clarke et al., 2021). Additionally, one cross-sectional survey examined occupational therapy practitioners’ reported use of ACT across clinical practice settings without specifying a single service context (Coleman et al., 2019). Across settings, ACT interventions were delivered in individual and group formats, most commonly within interdisciplinary teams.

What Outcomes Have Been Reported From Occupational Therapy Practitioners’ Use of ACT?

Across studies, reported outcomes primarily reflected changes in psychological flexibility and core ACT processes, rather than occupation-specific measures. The most consistently reported improvements were in pain acceptance, psychological flexibility, and reductions in cognitive fusion and experiential avoidance, particularly within chronic pain populations. Furthermore, occupational therapy practitioners reported that combining ACT and occupational therapy enhances pain rehabilitation and the likelihood of behavioral change (Haage & Tjörnstrand, 2024).

Many studies also reported improvements in distress-related variables, including reductions in depression, anxiety, psychological distress, and pain-related fear or catastrophizing, as well as improved emotional functioning and increased engagement in valued life domains (e.g., Daly-Eichenhardt et al., 2016; Hayes et al., 2011; Vowles et al., 2007; Vowles & McCracken, 2008; McCracken et al., 2005, 2015; Rider & Tay, 2022; Scott et al., 2017; Trompetter et al., 2014).

Functional outcomes were reported less consistently but included improvements in pain interference, physical and psychosocial disability, and activity engagement, particularly within comprehensive rehabilitation settings (e.g., McCracken et al., 2005, 2015; McCracken & Jones, 2012; Rider & Tay, 2022; Scott et al., 2017; Vowles et al., 2007; Vowles & McCracken, 2008). However, occupation-specific outcome measures were infrequently used, and improvements were typically described in terms of functional disability or participation broadly defined rather than discrete occupational performance metrics.

Quality of life and wellbeing were also assessed, with several studies reporting positive changes following ACT-based interventions (e.g., Clarke et al., 2012; Gaudiano et al., 2020a). In pediatric/adolescent contexts, outcomes included reductions in cognitive fusion and improvements in acceptance, social and physical functioning, mindfulness, emotional regulation, and stress reduction (Clarke et al., 2021; Kemani et al., 2018; Makki et al., 2018), and in one study, caregiver acceptance and psychological flexibility improved (Kemani et al., 2018).

Overall, reported outcomes across studies suggest that ACT-informed interventions delivered or co-delivered by occupational therapy practitioners were associated with improvements in psychological flexibility processes, emotional functioning, and pain-related disability, with less consistent reporting of occupation-based performance outcomes. Because most interventions were delivered within interdisciplinary programs, attribution of outcomes specifically to occupational therapy services was often unclear.