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Acceptance
and
Commitment
Therapy


(ACT)
for
Psychosis: 

 
(8/11)

An
18
Session
Group
Therapy
Protocol

Adria N. Pearson, PhD  
Department of Medicine, National Jewish Health and Department of Psychiatry, 
University of Colorado at Denver; PearsonA@NJHealth.org 
Richard Tingey, PhD  
VA Long Beach Healthcare System; Richard.Tingey@va.gov 
 
Introduction



Intended Clinical Population for this Protocol 

This
is
an
ACT
group
protocol
for
individuals
experiencing
psychosis.
It
is
intended
for
people
who
experience
psychotic

symptoms
including
hallucinations
(of
any
sensory
type)
and
delusions
(of
any
type)
as
part
of
a
psychotic
spectrum
disorder.

This
protocol
does
not
specifically
address
mood
symptoms,
although
individuals
with
accompanying
mood
symptoms
(e.g.

schizoaffective
disorder)
may
be
included
in
treatment.
It
also
does
not
specifically
address
recovery
from
substance
use.

However,
clients
with
psychotic
symptoms
with
co‐occurring
substance
use/dependence
may
benefit
from
this
protocol
and

may
be
included
in
treatment.
The
protocol
was
developed
with
and
for
people
who
have
been
experiencing
intense

psychological
distress
for
a
long
time—in
the
old
vernacular,
a
chronic
condition.
We
believe
much
of
it
is
applicable
to

individuals
with
more
acute,
early
stage
or
other
severe
mental
health
conditions,
but
adaptations
may
be
necessary,
even

re‐sequencing
the
presentation
of
the
ACT
core
processes.
The
protocol
is
intended
to
be
conducted
by
two
therapists
in
a

group
format.
While
there
is
no
specific
client‐limit
for
the
treatment,
we
recommend
a
maximum
of
12
clients
per
group
for

ease
and
effectiveness
of
the
therapy
exercises.



Structure of the Protocol  

The
protocol
includes
six
sections
each
based
on
one
of
the
six
core
processes
of
ACT.
At
the
beginning
of
each
section,
the

overarching
purpose
of
targeting
the
core
process
with
respect
to
this
population
is
described.
This
section
introduction
also

lists
the
goals
the
section
is
designed
to
help
clients
achieve.
Within
each
section,
three
therapy
sessions
with
relevant

exercises
are
devoted
to
specifically
target
the
core
process
being
addressed.

Each
session
begins
with
the
purpose
or
goal

it's
designed
to
achieve.



Given
that
ACT
is
a
fluid
therapy,
it
is
impossible
to
exclusively
parse
out
each
core
process
per
section.
Since
they
overlap

and
blend
together
to
enhance
psychological/behavioral
flexibility,
we
also
discuss
at
the
beginning
of
each
section
other

core
processes
that
may
likely
emerge
and
could
be
attended
to
in
that
section's
three
group
sessions.
Therefore,
while
the

focus
in
a
section
is
intended
to
be
on
a
specific
core
process,
others
will
inherently
emerge
and
can
also
be
lightly
introduced

or
addressed
in
more
depth.
For
example,
when
teaching
clients
to
notice
their
thoughts
as
a
tool
for
present
moment
focus,

this
"noticing"
also
functions
as
defusion.
Additionally,
acceptance
will
also
likely
emerge
when
learning
to
be
present

moment
focused
with
feelings.
Both
of
these
core
processes
are
specifically
targeted
in
later
sections,
but
along
with
others,

may
show
up
earlier
in
treatment.
The
descriptions
at
the
beginning
of
each
section
may
assist
with
this
blending,
and
the

group
leaders
may
choose
to
reference
other
core
processes
as
a
way
to
set
the
stage
for
upcoming
sections.
Because
of
this

and
other
reasons,
we
strongly
recommend
that
before
using
this
protocol
clinicians
first
become
familiar
with
ACT
therapy

and
each
core
process
(preferably
w/experience‐based
training)
so
that
they
can
consistently,
yet
flexibly
apply
the
protocol.


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 
 1


In
the
introduction
of
each
section,
we
also
provide
some
recommendations
on
how
to
address
therapy
process
issues

related
to
each
core
process.
This
includes
some
suggestions
on
how
to
address
therapeutic
issues
that
may
arise
regarding

the
core
process
with
this
population
in
an
ACT
consistent
manner.



The
Protocol

Sessions 1‐3: Learning to be Present: How to Feel and Be Here Now 
Contact
with
the
Present
Moment:
An
introduction
and
group
process
suggestions



Session
1:

Noticing
What’s
Outside:
The
World,
You
and
Me



Session
2:

Noticing
What’s
Inside:
Thoughts,
Feelings
&
Physical
Sensations



Session
3:

Why
I
can't
Be
Here—Noticing
What’s
Distracting



Sessions 4‐6: Defusing from the Noise:  Living With Thoughts and Voices  
Session
1:

Meeting
Your
Mind—The
Co‐Pilot


Session
2:

Experiences
and
Thoughts


Session
3:

Training
Your
Co‐Pilot


Sessions 7‐9: Acceptance: Identifying and Letting Go of the Struggle 
Session
1:

Unwanted
Thoughts


Session
2:

Unwanted
Feelings


Session
3:

Dropping
the
Rope—Willingness


Sessions 10‐12: Defining who "I Am": The Self as Content and Process, in Context 

Session
1:

I
am
the
Person
Who…


Session
2:

Who
is
the
“You”
who
notices?


Session
3:

The
Constant
“YOU”


Sessions 13‐15: Clarifying Values and Goals: Autonomy and Meaningful Direction in Recovery  
Optional
Session:

Values/Goals—What
I’ve
Been
Told 

Session
1:

Where
do
I
Want
to
Fly?


Session
2:

Defining
My
Next
Destination


Session
3:

Exploring
New
Terrain 

Sessions 16‐18: Committing to a Course of Action: Meaningful Living and its Barriers 
Session
1:

Turbulence
in
Flight:
What
Makes
for
a
Rough
Ride?

A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 2


Session
2:

Willingness
in
Action


Session
3:

Committed
to
a
Valued
Path


A Note on Beginning with Present Moment Focus 

We
begin
the
protocol
for
psychosis
with
present
moment
focus.
This
is
not
typical
of
many
ACT
protocols,
which
traditionally

begin
with
acceptance
(experiential
avoidance
and
creative
hopelessness).
The
shift
in
this
protocol
is
based
on
our

experience
conducting
ACT
groups
for
clients
with
psychotic
for
well
over
a
year.
Individuals
with
psychosis
have
immense

difficulty
being
in
the
present
moment.
Some
might
say
that
the
lack
of
present
moment
focus
with
these
clients
is
their

psychosis—a
break
with
reality
(the
present)
via
hallucinations
and/or
delusions.
From
an
ACT
philosophy,
however,
reality
is

self‐defined,
and
not
so
concrete.
Therefore,
clients
with
psychosis
are
in
fact,
in
their
own
personal
reality,
just
as
we
all
are.

Everyone
has
a
different
experience
of
life,
via
their
senses,
thoughts
and
feelings.
These
pull
all
of
us
away
from
noticing

what
is
going
on
in
our
environment.
Our
attachment
to
thoughts
and
feelings
as
truth
can
shift
our
behavior
towards
less

experience‐based
actions.
From
an
ACT
philosophy,
behavior
based
on
attachment
to
thoughts
or
avoidance
from
feelings

can
become
quite
narrow,
and
detached
from
one's
external
surrounds
or
personal
values.
Clients
with
psychosis
have
this

same
process
happening
(i.e
thoughts
and
feelings
pull
them
away
from
what
seems
an
apparent
response
to
their

environment
or
their
next
meaningful
action).
Auditory
or
other
hallucinations
are
the
vehicle
and
are
arguably
extremely

strong
stimuli
that
pull
one
away
from
the
present
moment.

Delusions
that
become
the
individual’s
personal
truth,
are
also

very
powerful
and
shift
behavior
away
from
the
present.
With
hallucinations
and
delusions
being
common
and
sometimes

nearly
constant
for
these
clients,
being
present
with
relationships
in
a
group
setting
is
extremely
difficult.
Without
this

capacity,
however,
it
would
be
difficult
if
not
impossible
to
notice
avoidance
strategies,
what
is
being
avoided,
and
what
is

valued.



By
beginning
with
present
moment
focus,
we
intend
to
address
the
difficulty
clients
with
psychotic
symptoms
have
with

being
present.
To
actually
be
present
moment
focused
inherently
involves
dropping
experiential
avoidance
behaviors,

accepting
one’s
experience,
and
defusing
from
thoughts.
It
is
not
the
intention
of
the
first
three
sessions
to
accomplish
all

these
goals,
but
to
begin
building
this
necessary
foundation
for
them
and
other
core
processes.
Specifically
our
intention
in

beginning
with
present
moment
focus
is
to

1)
invite
clients
to
consider
being
more
present,
2)
teach
them
how
to
notice
via

practice
what
is
happening
in
the
present
moment
(we
will
use
this
throughout
the
protocol),
and
3)
create
a
space
for

effective
group
work
by
initially
developing
a
context
of
present
moment
focus.
By
leading
with,
and
emphasizing
the

importance
of
being
present,
clients
will
be
able
to
use
this
as
a
tool
to
practice
being
present
as
an
alternative
to
experiential

avoidance
behaviors.
Additionally
if
the
begin
practicing
noticing
present
moment
stimuli
early
on
(i.e.
each
other,
thoughts,

feelings,
etc),
they
will
be
primed
for
later
sessions
where
they
will
learn
language
for
what
they
are
already
beginning
to
do:

defuse,
accept,
value
and
act
accordingly.


A Note about the Therapist’s script  

You’ll
notice
that
we
provide
script
in
quotations.
This
is
not
intended
to
be
read
verbatim
(although
it
may
be
if
you
find
it

useful).
The
quoted
script
is
intended
as
a
guide
for
the
therapist
in‐between
exercises.



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 3


Learning
to
be
Present:
How
to
Be
Here,
Now


Goals,
Purpose
and
Process
Suggestions
for
Sessions
1‐3

The
following
three
group
sessions
are
intended
to
target
the
core
process,
contact
with
the
present
moment.

This
core
process
in
ACT
has
three
overarching
goals:



1.
To
notice
what
is
present
externally
in
the
environment



2.
To
notice
thoughts,
feelings,
hallucinations,
and
physical
sensations
(i.e.
private
experience)



3.
To
discriminate
what
is
present
internally
and
externally,
and
to
describe
these
processes
without
excessive

judgment



The
outcome
of
these
skills
is
to
develop
self
as
process:
“I
am
feeling…”
“I
am
thinking….”


The
Purpose


The
purpose
of
these
three
sessions
is
to
teach
clients
how
to
be
present
in
group,
and
in
so
doing,
develop
an

effective
space
for
working.
If
one
is
physically
present,
but
not
attending
to
the
present
moment,
identifying

control
strategies,
areas
of
avoidance,
values
and
goals
is
next
to
impossible.
Therefore,
our
protocol
begins
with

helping
clients
become
aware
that
they
have
a
choice
of
whether
or
not
to
be
in
contact
with
the
present

moment,
and
if
they
choose
to
be,
teaching
them
some
skills
to
do
it.
For
some
groups,
it
may
be
advantageous
to

gently
introduce
present
moment
focus
prior
to
starting
the
protocol
by
engaging
them
in
1‐2
mindfulness

sessions
(breathing,
raisin
exercise
etc.).


Addressing
other
core
processes
in
becoming
present


Mindfulness
is
one
technique
utilized
to
target
increased
awareness
of
internal
and
external
experience,
thereby

fostering
contact
with
the
present
moment.
Effective
practice
of
mindfulness
involves
both
acceptance
of
one’s

experience
(versus
avoiding)
and
becoming
defused
from
one’s
thoughts.
Acceptance
and
defusion
are
two
ACT

core
processes
that
will
be
introduced
to
clients
later
in
treatment.
However,
in
this
initial
section,
clients
will
be

asked
to
mindfully
notice
their
thoughts
as
part
of
what
is
happening
in
the
present
moment.
They
will
also
be

asked
to
notice
their
feelings
(some
experiencing/avoiding
of
them
will
necessarily
occur),
as
well
as
tangible

stimuli
in
the
environment
for
this
same
purpose.
Thus
in
terms
of
how
to
be
present
in
group,
control
strategies

(barriers
to
being
present,
such
as
cognitive
fusion
and
experiential
avoidance)
are
introduced,
and
acceptance

and
defusion
inherently
addressed.
Clients
will
not
be
asked,
however,
to
examine
their
control
strategies,

workability
or
fusion
with
thoughts
in
a
global
way
(i.e.
in
terms
of
how
these
processes
are
impacting
their
life).

These
aspects
will
be
intentionally
targeted
later
in
the
defusion
and
acceptance
sections.
The
therapists
may

choose,
depending
on
their
facility
with
ACT,
to
reference
these
other
core
processes
as
they
emerge
and
use

language
that
will
prime
clients
for
the
deeper
experience
with
them
that
will
be
coming.



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 4


Suggestions
for
group
process:



Interventions
targeting
reductions
in
avoidance,
and
those
providing
positive
reinforcement
for
being
present
are

important
at
the
very
beginning
of
treatment.
The
therapists
should
model
present
moment
focus.
Use

statements
like
“I’m
noticing
that….”
when
referring
to
a
behavior.
This
ties
observations
to
the
present
moment,

provides
positive
reinforcement
for
being
present,
and
teaches
a
non‐judgmental
stance
the
clients
can
adopt.

From
a
different
perspective,
this
noticing
can
point
out
that
being
present
is
difficult,
drawing
the
client’s

attention
to
the
fact
s/he
is
not
present.
By
doing
this,
you
are
pulling
the
client
into
the
present
moment.


For
example:



“I
noticed
that
Dan
and
Tim
were
smiling
and
laughing
when
talking
with
one
another
in
the
last
exercise.
You

guys
appeared
to
be
really
engaged
and
present
with
one
another!”


Or



“I
just
noticed
that
Tom
looks
pretty
tired.
Are
you
feeling
sleepy
right
now?
Are
you
willing
to
stay
with
us
for
this

next
exercise?”


Choosing an “orienting” therapist:  

Throughout
all
the
protocol
groups,
but
particularly
for
the
first
three,
one
therapist
should
be
selected
to
orient

clients
back
to
the
present
moment
who
are
not
attending
or
participating
in
group.

This
therapist
may
gently

interrupt
a
client
who
is
speaking
when
they
notice
that
another
client
is
looking
at
the
floor,
sleeping,
or

otherwise
not
attending
to
the
person
speaking.
The
therapist
may
make
a
noticing
comment
and
ask
that
the

person
re‐orient
to
what
the
other
client
is
saying.
Depending
on
the
focus
of
the
group
at
the
time,
s/he
may
also

inquire
as
to
what
is
distracting
the
client
from
attending
to
the
present
moment
(i.e.
is
it
something
external
or

internal.
If
it
is
internal,
is
it
a
physical
sensation,
a
voice,
an
emotion
or
a
thought).
Assist
the
client
in
labeling

what
experience
was
distracting,
then
re‐orient
him/her
towards
the
client
who
was
speaking.
You
may
process

this
with
the
client,
who
was
interrupted
by
saying
something
like,



“I’m sorry to have interrupted you. It’s important to me that each client pay close attention to what is happening 
presently (i.e. you were speaking). At times we all become distracted from the present moment. So, in this group, I 
may be interrupting people from time to time when I notice another client struggling with staying present.”  

Creating a Supportive Context to Teach Present Moment Focus  

Once
you
have
modeled
noticing
and
gently
interrupting
clients
who
are
not
paying
attention,
you
may
tell
clients

that
they
also
may
do
this.
It
is
usually
most
effective
when
a
client
is
brought
back
to
the
present
moment
by
a

peer
versus
the
facilitator.
Ideally,
an
environment
of
supportive
collaboration
should
be
fostered
in
the
group
by

the
therapists,
where
the
value
is
to
be
present.
If
this
can
be
modeled
from
the
outset
by
not
being
permissive
or

punitive
about
clients
“checking
out”,
a
context
of,
“This
is
a
group
where
it’s
important
to
be
present”
will
be

created.


Along
this
line,
you
may
choose
to
suggest
to
clients
that
they
ask
for
help
in
being
present.
You
may
state
early
in

the
group
that
if
someone
is
tired
or
otherwise
having
a
hard
time
focusing,
they
let
the
therapists
or
group
know.

A
brief
discussion
can
ensue
regarding
the
group’s
willingness
to
help
each
other
stay
present
if
members
are

willing
to
ask
for
this,
and
what
the
limits
of
the
help
might
be.
This
is
an
opportunity
for
the
therapists
to
provide


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 5


a
non‐punishing,
helpful
context
in
which
to
improve
the
present
moment
focus
skill.
Additionally,
since
this
is
a

skill,
the
therapists
and
other
clients
could
be
designated
as
coaches
for
present
moment
focus.
Using
the
word

“coach,”
emphasizes
that
it’s
not
easily
learned,
takes
practice,
and
helps
minimize
shame
and
guilt.


Discussing what is Distracting 

As
alluded
to
earlier,
in
this
segment
of
treatment,
discussion
of
what
gets
in
the
way
of
being
present
should
be

limited
to
noticing/identifying
the
experience
and
labeling
it
as
internal
or
external
(i.e.
it
was
external,
I
keep

hearing
the
lawn
mower
outside
and
it’s
distracting
me;
or
“It’s
internal,
it’s
a
feeling,
I’m
angry
about
something

that
happened
this
morning”).
Instead
of
yielding
to
the
likely
press
from
the
client
to
further
discuss
their

experience,
the
objective
is
to
help
the
client
notice,
label
and
reorient
to
the
present.
At
times,
this
may
not
be

easy.
To
do
this,
help
the
client
focus
on
something
(anything)
that
is
happening
at
the
present
moment
in
the

group.
Validate
that
the
experience
must
be
distracting,
and
state
that
you’d
like
to
help
the
person
orient
to

what
is
currently
happening
in
group.
The
rationale
for
not
moving
further
into
a
discussion
about
their
distracting

experience
is
that
it
takes
them
away
from
the
task
of
being
focused
on
what
is
happening
in
the
group.
Later
in

the
protocol,
there
will
be
plenty
of
opportunity
for
clients
to
move
into
an
emotion
while
being
in
the
group.
In

these
first
three
sessions,
the
point
is
to
have
clients
learn
to
discriminate
what
is
distracting
by
noticing,
labeling

it,
and
then
returning
to
what
is
happening
(i.e.
someone
is
sharing,
an
exercise
is
going
on,
etc.)
In
short,
when
a

client
is
distracted:
notice,
validate,
label
and
reorient.


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 6


Session
1:

Noticing
What’s
Outside:
The
World,
You
and
Me


Purpose:
The
purpose
of
this
session
is
to
enhance
present
moment
focus
by
drawing
clients’
attention
to
what
is

in
their
external
environment.
By
using
the
5
senses,
attention
is
drawn
towards
the
external
environment
in
the

group
setting.



Prepare:  In
starting
this
treatment
protocol,
select
a
method
that
you
will
use
to
begin
each
group
(some
external

stimuli)
that
orients
clients
to
the
present
moment.

One
recommendation
is
a
sound
such
as
the
chime
of
a
bell.

This
uses
the
sense
of
hearing
to
bring
clients’
attention
to
the
present
moment.
Whatever
method
is
selected

should
be
brief,
and
should
occur
at
the
beginning
of
every
group.
This
will
serve
as
a
conditioned
stimulus
for

bringing
attention
to
group.



Introduction To the ACT groups:  

Agreement
to
value
confidentiality:
Begin
with
a
reminder
that
the
personal
information
shared
in
the
groups

need
to
stay
in
the
group,
so
that
we
can
respect
and
value
each
other's
privacy.



Introduce
the
ACT
series,
explain
that:


1.

ACT
stands
for
Acceptance
and
Commitment
Therapy…that
this
therapy
focuses
on
the
acceptance
of
things

we
can't
change,
and
becoming
committed
to
finding
and
moving
towards
what
is
meaningful
to
us.



2.
There
will
be
18
groups,
one
each
week,
in
this
series
of
psychotherapy…that
one
of
the
primary
purposes
of

these
groups
is
to
learn
how
to
really
be
present—not
only
being
physically
here,
but
also
mentally
and

emotionally
here.

Explain
that
being
present
makes
it
possible
to
really
get
involved
in
treatment,
define
what
is

important
to
you,
and
decide
how
you
can
work
towards
achieving
it.



Introduction
to
this
1st
Session:


Say
something
like,
"The purpose of today’s group will be to experience being more present today by  using our 
senses to be aware of what is going on in the room."

As
an
example,
the
therapist
uses
the
preselected
external

stimuli
(the
bell)
to
orient
the
clients
to
the
group.



Ring
The
Bell
&
instructing
clients
to
listen
to
its
sound.



Briefly
ask
what
the
clients
noticed
about
the
sound.
Elicit
a
few
comments.


Next
say
something
like, “Every day we walk around in our home/neighborhood and use our senses to guide us. 
There is a lot to take‐in with our senses in the world. Think about a busy street corner! Isn’t true that sometimes 
we’re caught up in our thoughts and might not notice someone standing right in front of us? It’s no wonder 
sometimes we bump into each other! Have you ever lost an item, like your keys or your wallet and found out that it 
was right in front of you all along?” 

(Elicit reactions from clients) 

A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 7


“It’s true, that it might be impossible to take in every detail around us at all times. We somehow decide what to 
pay attention to. How do we decide what to pay attention to?  

(Elicit reactions from clients) 

Next
say
something
like, “Sometimes something unexpected grabs our attention. Think about that busy street 
corner again with many cars going by. When someone honks their horn, we tend to look in that direction, right? 
Maybe that’s similar to what you did when Dr._________ rang the bell today‐ you looked in that direction! 
Sometimes sounds guide us to pay attention. Other times, sights might direct our attention. For example, if it 
suddenly started raining outside, that sight might take our attention out the window. But what about in group? 
How do we decide who or what to pay attention to?”  
 
(Elicit reactions from clients) 

Next
say
something
like, “Paying attention to people and things around us is one way we make decisions about 
what to do in life. Noticing, and becoming aware of what is around us connects us with the experiences we are 
having in life. Imagine a horn honking at that busy street corner. Looking in that direction may let us know to step 
back to avoid an accident. Maybe noticing the rain outside lets us know to carry an umbrella. We end up changing 
our behavior based on things we notice with our senses. Agreed?” 
 

(Elicit reactions from clients)  

Next
say
something
like, “So, here we are together, in a group, in a room for 45 minutes a week. Do we pay 
attention to each other? What aspects of each other do we notice? Do we only pay attention to people who talk? 
What about people who are silent? Do they go unnoticed?” 

“Before answering those questions, today we’re going to practice noticing what is around us in the room, including 
noticing each other using a couple of different exercises. The reason we’re practicing noticing is because, as we 
said, being fully aware with our senses helps us make decisions. Being more aware will help you make decisions 
about what to do in group. For example, if you practice being aware of another person, you might begin to notice 
when that person appears sad, is talking, or maybe when and if you’d like to respond to them. That’s just an 
example of the way being more aware can open up the decisions we make in life.”  

“We’ll begin by practicing noticing some things about this group room.” 

Exercise
1:
Noticing
the
room


Rationale:
This
is
a
continuation
of
noticing
external
stimuli.
The
process
of
doing
these
exercises
will
function
to

shift
clients’
attention
from
their
internal
experiences
(i.e.
thoughts,
feelings,
physical
states,
auditory

hallucinations,
etc.)
to
the
external
world.
This
will
be
an
important
skill
throughout
the
protocol
when
you
wish

to
reorient
a
client
to
what
is
happening
in
the
group
(i.e.
when
a
client
becomes
distracted
by
internal
stimuli,
is

sleeping,
etc.).


Step
1:
Ask
clients
to
stand
and
walk
around
the
room
without
speaking
(or
they
could
stand
in
one
place
and
look

around
the
room
depending
on
the
space
available
to
move).



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 8


Step
2:
Ask
clients
to
notice
three
things
that
people
simply
walking
through
the
room
might
not
notice.
Instruct

them
to
use
their
senses
to
notice
three
very
specific
details
of
the
room
(or
if
there
is
a
window,
three
details

outside
the
room).
Ask
them
to
really
“look
outside
themselves”,
paying
attention
with
their
eyes
to
details
in
the

room,
such
as
pictures,
carpet
color,
counting
the
number
of
chairs.
They
may
also
pay
attention
with
their
ears,

listening
carefully
to
any
sounds
in
the
room
(i.e.
the
air
conditioner
humming,
noises
outside
that
can
be
heard
in

the
room,
the
sound
of
their
own
breath).
Remind
them
that
in
order
to
notice
specific
details
in
the
room,
they

need
to
look
or
listen
closely.




Step
3:
After
4‐5
minutes,
bring
clients
back
to
the
group
for
a
discussion
of
this
exercise.
The
discussion
may

include
any
part
of
the
process
involved
in
the
exercise:
(i.e
what
was
it
like
to
walk
quietly?
Was
it
difficult?
How

did
it
feel
to
notice
specific
details?
Did
you
notice
anything
you
hadn’t
noticed
before?
Did
you
notice
things
that

you
wish
you
hadn't
noticed?)
As
part
of
the
discussion,
allow
clients
to
share
the
three
things
they
noticed.




“Next, we’ll practice noticing some things about each other.” 

Exercise
2:
Describing
the
Self
and
Another:



Rationale:



The
purpose
of
this
exercise
is
to
have
clients
practice
noticing
and
describing
something
about
themselves
and

then
about
another
person.
This
introduces
noticing
mostly
external
aspects
of
people—noticing
self
and
noticing

another.


Step
1:
Ask
clients
get
into
pairs.



Step
2:
Ask
each
client
to
introduce
themselves
to
the
other
person
and
state
three
facts
about
themselves.
Have

them
switch,
making
sure
each
client
provides
three
facts
to
the
other.



Step
3:
Bring
them
back
to
the
group,
and
have
the
clients
describe
the
three
facts
about
the
other
person,
plus

one
thing
they
noticed
about
the
other
person
while
the
person
was
sharing
their
facts.
This
could
be
their
hair

color,
clothes,
tone
of
voice,
facial
expression,
etc.



Group
Closure:


Explain
that
today
clients
became
more
aware
of
the
group
environment
and
of
another
person.
Explain
that
this

group
will
often
ask
clients
to
be
in
contact
with
the
present
moment,
to
really
be
here,
and
that
the
next
two

groups
will
be
further
discussing
how
to
do
this.
Allow
time
for
feedback
and
questions
from
clients
before

ending.


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 9


Session
2:

Noticing
What’s
Inside:
Thoughts,
Feelings
and
Physical
Sensations

Purpose: The
purpose
of
this
session
is
to
increase
awareness
of
thoughts,
hallucinations,
physical
sensations
and

feelings
through
describing
and
experiencing
them.
Being
present
with
what
the
client
is
experiencing,
and

describing
that
experience
is
the
primary
focus
(although
inherent
in
this
process
is
defusion).
Discussion
of
these

experiences
as
ones
clients
“have”
versus
ones
which
define
their
truth
is
important
(i.e.
“I’m
having
the
thought

that
I’m
worthless”
versus
“I
am
worthless”.)



Prepare:  1.
Cloth
bags
(1
for
each
client)
without
any
design
on
the
exterior‐‐purchased
at
craft
stores
for
minimal

cost.
 

2.
Colored
markers.


3.
Internal
experience
3
by
5
cards
for
each
member
with
these
incomplete
sentences
on
them,
"I'm
having
the

thought
that
___________;
I'm
having
the
emotion/feeling
of
___________;
I'm
having
the
physical
sensation
of

___________;
I'm
hearing
a
voice
(hallucination)
saying
___________."


4.
Create
an
Example
Bag
filled
with
several
internal
experience
cards
with
the
blanks
filled
in.


Ring The Bell:


 Briefly Review Last Session:  

Briefly
remind
clients
about
confidentiality.
Ask
clients
what
they
remember
about
our
last
group
(briefly
elicit

responses).
If
needed,
summarize
that
last
week
we
discussed
the
usefulness
of
really
being
present
and
we
did

some
exercises
on
using
our
senses
to
notice
things
around
us‐‐the
room
and
members
in
the
group.
Ask
clients

how
it
might
be
useful
to
be
physically,
mentally
&
emotionally
present
(if
needed,
review
that
being
present

provides
information
to
make
decisions
and
connect
with
people
&
things).


Introduction to the Session: 


Remind
clients
that
in
this
group
will
be
asking
them
to
practice
being
present
by
listening
and
actively

participating
in
group
exercises.
This
may
include
you
calling
on
them
by
name
if
they
appear
to
be
not
present.

This
is
not
to
be
punishing,
but
to
be
helpful
in
drawing
their
attention
to
what
is
happening
in
the
present

moment.



Say something like, “Last week we focused on using our senses to notice things going on around us—the room and 
group members. Today, we’re going to practice noticing what we have going on inside us—in our mind, heart and 
body. These are things like thoughts and feelings, experiences like hearing voices, and physical feelings like hunger, 
exhaustion, or physical discomfort. Just like experiences on the outside can grab our attention, these internal 
experiences can also divide and pull our attention in different directions.”  

A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 10


Use
10
minutes
for
a
discussion
of
internal
experiences.
The
purpose
of
this
discussion
is
to
begin
to
define

different
types
of
internal
experiences,
and
also
to
use
the
discussion
as
opportunity
to
practice
present
moment

focus.
You
may
use
the
following
questions
to
guide
the
discussion.



“Can anyone give me an example of an internal experience that would really grab your attention?”  

(Therapist elicits examples from clients)  

 “What about thoughts? Does anyone ever have thoughts that take you away to a totally different place, away 
from this room?”  

(Elicit examples from clients)  

“What about hearing things that other people don’t seem to hear, or seeing things that only you can see?” 

"Are some of these internal experiences more pleasant than others?" 

(Therapist opens a dialogue about hallucinations) 

During
this
discussion,
there
will
be
participators
and
non‐participators.
At
this
juncture,
one
therapist
needs
to

facilitate
the
discussion,
while
the
other
therapist
attends
to
clients
who
appear
to
not
be
present.
There
are

several
ways
to
do
this.
You
may
call
on
individuals
to
be
more
present
(i.e.
“John,
I’m
noticing
you’re
lost
in

thought.
Can
you
practice
listening
to
what
is
being
said
right
now?”).
If
the
group
is
large,
you
may
choose
to

break
the
group
into
two
smaller
groups
(each
therapist
taking
one
group)
so
that
everyone
has
opportunity
to

participate
in
the
discussion.
Alternately,
you
can
remind
the
group
as
a
whole
that
you’ll
be
asking
people
to
use

their
senses
to
remain
as
present
as
possible
to
what
is
happening
outside
themselves.
Therefore,
you’re
be

asking
them
to
practice
being
present
to
“what’s
going
on
in
the
group”
(per
the
last
session’s
topic)
as
they
begin

to
discuss
internal
experiences.



After
some
discussion
introduce
the
exercise
for
this
group.



Exercise:

What
I
am
Carrying



Rationale:  

This
exercise
is
a
metaphor
for
how
to
be
aware
of
and
"have"
internal
experiences
(i.e.
to
carry
them
lightly).
It

also
is
an
exercise
to
teach
discrimination
between
the
following
internal
experiences:
Thoughts,
physical

sensations,
feelings
and
voices‐
auditory
hallucinations.
Also,
the
exercise
teaches
how
to
describe
those
internal

experiences
by
writing
them
on
a
card.
The
bag
and
card
metaphor
will
be
continued
over
several
groups.
This

metaphor
is
used
early
to
create
a
way
to
begin
to
discuss
difficult
experiences
in
an
ACT
consistent
manner.
By

immediately
separating
difficult
internal
experiences
from
the
person
(i.e.
by
writing
them
on
a
card
and
placing

the
card
in
a
bag)
the
stage
is
set
for
defusion,
acceptance
(i.e.
carrying
experiences
with
us),
and
self
as
context

(i.e.
I’m
a
person
who
is
carrying…).
Initially,
however,
this
exercise
is
intended
to
facilitate
present
moment
focus

through
discrimination
of
internal
experiences
and
labeling
of
those
experiences.



Step
1:
Show
your
example
bag
to
the
group.
Explain
that
everyone
carries
various
thoughts,
feelings,
physical

sensations
and
sometimes
has
other
experiences
(like
hallucinations).
Like
leaving
our
home
each
day
with
a

backpack,
we
leave
our
house
and
enter
the
world
each
day
with
different
things
in
our
pack.
Each
of
us
carries

different
things
in
our
bag
to
group
each
day.



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 11


Step
2:
Set
your
example
bag
on
the
floor,
and
ask
if
clients
can
tell
what
is
in
the
bag.




Say
something
like,
“Let’s pretend that I’m carrying all my thoughts, feelings and physical sensations in this bag. 
Just by looking at it, can you tell what I might be carrying in it? You could guess, but unless I show you what’s 
inside the bag, you wouldn’t know for sure what thoughts and feelings exist in here. It’s like that with looking at 
each other. We can guess, but might not be completely accurate at knowing what thoughts, feelings or physical 
sensations another member might be having. They are private and only known to others when we share them. It’s 
like that also with having hallucinations. Isn’t it true that only you can hear the voices that you carry with you?” 


Allow
some
discussion:
Some
clients
will
think
that
other
people
can
hear
their
thoughts,
or
know
what
they
are

feeling
by
looking
at
them.
Address
this
with
a
brief
discussion
such
as:



“Sometimes we may believe people can tell we’re carrying a heavy load in our bag of feelings and thoughts. We 
might be carrying the thought,  ‘don’t they know I’m weighed down by 100 pounds in this bag?’ Sometimes it’s 
true that others can tell that we’re carrying a heavy load versus a lighter load. How, for example, would you be 
able to tell if this bag was heavy for me to carry?”  

Step
3:
Elicit
examples
of
how
people
would
know
a
person
was
carrying
a
heavy
bag


“I might be walking slower. I might have an expression on my face (therapist might want to pretend the bag is 
heavy). But, in order to notice that I’m carrying some heavy stuff with me, you’d have to be noticing me, right?! 
You’d have to be present here with me to notice that I’m struggling with this grocery bag”. 

(This brings attention to the importance of being present to what is external once more). 

Step
4:

At
this
juncture,
pass
the
bag
to
a
few
members
and
ask
them
to
pull
out
a
card
and
read
what
is
on
it.

This
stands
as
a
metaphor
for
you
sharing
what
you
are
carrying
in
your
bag.


Bring
clients’
attention
to
the
fact
that
the
phrase
“I’m
having”
precedes
each
internal
state.
Discuss
that
having

thoughts,
feelings,
hallucinations
and
physical
states
are
similar
to
carrying
lunch
in
our
backpack.
While
carrying
a

can
of
soda,
you
wouldn’t
say
“I
am
soda”.
You’d
say
“I
have
some
soda”.
Once
you
use
the
soda,
you
don’t
have
it

anymore.
Feelings
and
thoughts
are
like
that,
ever‐changing.



You
may
want
to
emphasize
physical
states
that
come
and
go,
such
as
having
a
headache.
It
is
an
uncomfortable,

yet
temporary
state.



Allow
time
for
discussion
on
this
point.


Step
5:

Next,
pass
around
bags
for
clients
and
have
them
write
their
name
on
the
front
of
the
bag
(or
prepare

this
before
group).



Step
6:
Tell
clients
that
inside
the
bag
are
four
cards
on
which
they
may
write
a
thought,
a
feeling,
a
physical

state
or
a
hallucination
(a
voice)
they
are
having
right
now.
Ask
them
to
take
4‐5
minutes
to
choose
two of the 
four cards and
write
the
experiences
they
are
currently
having
on
the
card.



You
may
need
to
provide
an
example
for
clients
(i.e.
One
the
card
that
says
“I’m
having
the
thought
that…..”
the

client
might
write
“this
exercise
is
stupid”).
Each
therapist
will
need
to
help
clients
in
doing
this.
Walk
around
the

room
and
provide
clients
with
individual
attention.
Provide
additional
attention
for
those
who
are
not

participating
in
the
exercise.



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 12


Step
7:
Bring
clients
attention
back
to
the
group
and
ask
that
each
client
share
one
experience
they
are
having

now
that
they
wrote
on
a
card.



Use
this
exercise
as
an
opportunity
to
discriminate
between
thoughts,
voices,
feelings
and
physical
sensations
as

different
types
of
experiences
that
people
can
choose
to
be
present
with.
Listen
to
see
if
the
group
is
avoiding

certain
types
of
experiences
(feelings,
hallucinations,
etc.;
or
experiences
that
may
be
seen
as
negative
or

positive).
If
so,
notice
this
with
the
group
and
if
needed,
interject
examples
to
model
inclusiveness
of
a
full
range

of
experiences.


Step
8:
Have
a
discussion
about
what
internal
experiences
clients
experienced
during
this
exercise.
Discuss
the

process
of
the
exercise
as
the
conclusion
to
the
group.



Group Closure 

Inform
clients
that
the
bag
they
received
is
theirs
to
keep
for
the
group.
It
will
be
their
place
to
put
different

experiences
they
identify
(i.e.
by
writing
them
down
and
putting
them
inside
the
bag).
Explain
that
they
will
be

collecting
these
experiences
over
the
course
of
several
weeks,
and
may
choose
to
share
them
or
keep
them

private.
The
bags
will
be
placed
next
to
each
client
during
subsequent
groups,
with
a
few
3
by
5
cards
and
a

marker.
They
will
be
invited
to
write
down
thoughts,
voices,
physical
sensations
and
feelings
at
certain
times

during
group
and
place
these
in
the
bag.
They
can
either
keep
the
bag
open
or
roll
the
top
of
the
bag
down
and

close
it
tight,
as
representation
of
willingness
to
share
their
experiences
in
group
that
day.
Instructions
for
this

process
will
be
given
again
in
subsequent
groups.



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 13


Session
3:

Why
I
Can't
Be
Here—What’s
Distracting?

Purpose: The
objectives
of
this
session
are
to
help
clients
to
begin
to
discriminate
between
thoughts,
feelings,
and

physical
sensations;
and

increase
their
awareness
that
noticing
these
experiences
provides
them
with
a
choice
as

to
how
to
react—to
focus
on
them
or
turn
their
attention
to
something
else.



Prepare: Bring clients bags, blank 3x5 cards and pens. Bring posters with the 4 types of internal experiences 
written on them: “I’m having thoughts of..., I’m having physical sensations of… etc.” 

Group Orientation:   Ring
the
Bell


Briefly Review Last Session: 

Ask
clients
if
they
remember
what
we
did
last
session.
If
they
struggle,
draw
their
attention
to
the
bags.
Make

sure
that
all
clients
recall
what
they
were
asked
to
put
into
their
bags
and
what
the
bags
represent
(re‐explain
if

necessary).
If
clients
can
remember,
provide
praise
for
having
been
present‐enough
in
group
to
recall
the
exercise

the
following
week.



Group Introduction:  

Explain
that
today
we’re
going
to
notice
what
internal
experiences
we’re
having
that
distract
us
and
make
may

make
it
hard
for
us
to
be
mentally/emotionally
here
in
this
group.



Exercise
1:
Where
is
your
attention?



Rationale:  

This
exercise
asks
clients
to
discriminate
thoughts,
voices,
feelings
and
physical
states
by
asking
which
of
these

internal
experiences
is
most
distracting
to
them
at
the
present
time.
This
enhances
present
moment
focus
by

asking
clients
to
get
in
touch
with
their
internal
experience.
As
well,
the
discussion
that
is
part
of
the
exercise
will

facilitate
description
of
internal
states.



Step
1:
Identify
the
different
types
of
internal
experiences


Say
something
like:
“Last
week
we
wrote
down
a
thought,
a
feeling
or
emotion,
a
voice
or
hallucination,
or
a

physical
sensation
that
we
might
be
having
(tape
the
“internal
experiences”
posters
to
the
door
as
you
list
them).




On any given day, we likely have many of these experiences. Today, right now we’d like to know which one of 
these is most distracting or bothersome for you. What makes it hard for you to really be here; or even makes it so 
you  can’t be mentally/emotionally here (it’s so distracting you mentally “check‐out”). We’ve given you some 
general options to choose from on these posters.. 

Step
2:
Invite
the
members
to
“notice”
what
is
distracting
them:



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 14


Say
something
like:

“Please
take a few moments to notice what, right now, is distracting you from really   being 
here. It might be physical sensations like pain, tiredness, being ill; thoughts about something that happened before 
group or even a long time ago, or something you are worried about;  hallucinations, like voices you may be hearing 
right now; or feelings like anger, sadness, or even a positive emotion that is about an event in your life. In fact, you 
may have many of these experiences happening all at once. Most of us do. You might have a headache and be 
worried.   Take a moment to notice. 

Step
3:
Have
clients
physically
move
to
different
locations
based
on
their
most
distracting
internal
experience.

(If
in
a
large
room,
you
can
use
corners
of
the
room,
if
not
you
can
use
the
hallway
&
adjoining
areas).


Say
something
like:

“Instead of describing out loud what’s most distracting to you right now, we’re going to ask 
you to move to different area, based on what’s bothering you most.” Ask
everyone
to
hold
their
bag
and
move
to

the
center
of
the
room.



a. One
therapist
asks: “Who is most bothered right now by a physical sensation—headache, tiredness, physical 
pain, etc.? If so, please move to the back (window) side of the room and stay standing. 

b. The
other
therapist
asks:

“Who is most bothered right now by some upsetting,, worrisome, scary, or 
depressing thoughts or memories?  If so, please move with me out into the hall and into the waiting room 
and stay standing. 

c. One
therapist
now
asks: “Who is bothered or distracted by hearing voices or some other hallucination? If so, 
please walk down the right hallway and stay standing.”  

d. The
other
therapist
asks: “Who is also bothered or distracted today by a feeling like, anxiety, sadness, 
depression or anger? If so, please walk down the left hallway and stay standing.” 

Step
4:

Have
clients
write
down
the
distracting
experience
they
are
having.


Provide
blank
3
by
5
cards
for
clients
and
ask
them
to
write
down
a
specific
physical
sensation,
thought,

voice/hallucination,
or
feeling
that
they
are
having
that
prompted
them
to
move
where
they
are
standing.
Tell

clients
to
place
these
cards
in
their
bag.



Step
5:

Have
clients
“notice”
group
members
who
are
having
similar
or
dissimilar
internal
experiences

compared
to
their
own.


a. Instruct
clients
to
continue
to
hold
the
bag
with
their
distracting
experiences
in
it.
Then,
ask
them
to
look

around
their
side
of
the
room
or
area
and
notice
who
else
is
standing
with
them.
Ask
clients
to
quietly

observe
this
for
about
30
seconds.
Note,
“Take a look around at your peers who are standing with you. 
They too are most bothered or distracted by a similar type of experience. Know that you are not alone.”  

b. Ask
clients
to
look
to
the
other
side
area,
side
of
the
room
at
their
peers
struggling
with
a
different
type
of

internal
experience.
Ask
clients
to
quietly
observe
who
is
standing
on
the
other
side
of
the
room
for
about

30
seconds.

Note,
“Now look to the other side of the room. Your peers over there are struggling with a 
different type of internal experience today.  

Step
6:


Have
clients
consider
if
they
are
having
more
than
one
type
of
internal
experience.


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 15


a. Ask
clients,
“Notice and consider if you might be distracted by more than one internal experience— feelings 
and voices/hallucinations, physical pain and thoughts, or some other combination?  Maybe even today, you 
struggle with two or three?” 

b. Ask
clients
to
move
to
the
center
of
the
area
used
(middle
of
the
room)
if
they
are
having
more
than
one

internal
experience.


c. Ask
these
clients
to
write
a
specific
example
on
their
card
of
the
other
internal
experience(s)
they’re

having.


d. Ask
them
to
take
a
moment
to
notice
their
peers
who
are
standing
with
them,
note,
“you
are
not
alone.”



Step
7:

Invite
the
clients
return
to
the
group
and
sit
down.
Thank
them
for
their
willingness
to
share
their

distracting
internal
experiences
by
standing
with
their
peers.
Begin
a
discussion
about
the
exercise.


Discussion
points
following
the
exercise


1.
This
exercise
helps
clarify
the
distinction
between
thoughts,
feelings,
physical
sensations
and
voices.
Point
out

that
clients
exercised
their
capacity
to
distinguish
these
by
noticing
what
was
internally
distracting
and
based
on

the
type
of
distraction,
moving
to
a
different
area.
How
did
they
do
this?
Elicit
an
example
of
one
of
each
type
of

distracting
experience.
You
may
ask
what
is
distracting
about
pain
(physical
or
emotional)?
What
is
distracting

about
the
voices
or
verbal
thoughts
in
our
mind?



2.
A
related
point
is
that
these
internal
experiences
are
very
powerful.
Discuss
why
members
sometimes
can’t
be

here
in
the
group
(mentally
&
physically).
Note
that
these
experiences
can
“move”
us
out
of
the
group
in
different

ways.
Does
it
sometimes
seem
hard
to
really
be
present
in
group?
When
we're
actually
somewhere
else,
what

might
we
miss?
Is
it
possible
that
just
as
our
internal
experiences
pull
us
out
of
the
group,
they
pull
us
away
from

the
life
we
might
want
to
live?


3.
This
exercise
provides
an
opportunity
to
begin
a
discussion
about
pain,
and
how
it
is
common
and
shared

among
all
humans.
Also,
this
is
a
nice
opportunity
to
ask
if
clients
are
willing
to
be
with
each
other,
support
each

other
in
sharing
their
painful
internal
experiences
in
the
group.




4.
Another
valuable
point
of
discussion
is
that
we
have
choices
in
what
to
pay
attention
to
(i.e.
internal
versus

external
experiences‐
and
within
internal
experiences,
we
can
choose
to
attend
to
physical
pain,
emotional
pain,

thoughts
or
voices).
With
all
the
external
stuff
going
on,
and
all
the
internal
experiences,
how
do
we
choose
what

to
attend
to?



Exercise
2:

Metaphor—fire
in
the
room:



(Suggested script)  

“Let’s pretend that as we were doing that exercise, we all started to smell smoke. How many of you think that 
smelling smoke, in that moment, would be more distracting than anything else going on either outside or in your 
own head or body? Would smoke be distracting enough that you might not move to any corner of the room when 
we asked you to move?  

Would you stay in the room, as we asked that you do? How about if you noticed a small fire building in the corner 
over there (therapist points). Would you still stay in the room? Probably not. We’d all probably leave. We’d make a 

A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 16


choice to pay attention to the fire, versus any instruction that I was giving for the exercise. If you decided to leave 
the room based on the fire, you’d be paying more attention to the fire in that moment than to any internal 
experience you were having. The fire, then, would be more distracting than anything else. 

Consider when the fire alarm sounds in the VA. How many people have heard the fire alarm go off in this building? 
When it does, what happens? Do we all jump up and leave the room?  

We don’t! We usually look to see if other people are leaving the building, using them as cues. Why? Well, because 
sometimes we have fire drills and we need to leave and go outside. But, at other times, the fire alarm is a false 
alarm so we really don’t need to leave the building.  

Our minds and bodies are kind of like that. Our mind will sometimes give us false alarms by telling us that a 
situation is dangerous when it really isn’t. You may have experiences with voices saying things that aren’t true. Our 
bodies even give us false alarms…have you even felt a little nauseous, and thought ‘maybe I’m coming down with 
the flu’, but you end up feeling better in an hour?”  

(Provide some time for discussion on this metaphor).  

“So, how do we know what types of experiences to attend to, and what to react to? We’ll talk more about that in 
later groups.”  

Group closure 

Thank
the
group
for
being
willing
to
share
their
experiences.
Ask
clients
to
pick
up
their
bags,
which
now
have
a

few
more
cards
in
them.
Remind
clients
that
they
have
written
down
some
experiences
that
feel
distracting,

maybe
distressing,
and
possibly
pretty
heavy.
Ask
how
heavy
the
bag
feels.
Point
out
that
these
groups
will
begin

to
teach
clients
to
hold
their
internal
experiences
lightly.
The
first
step,
it
should
be
pointed
out,
is
to
continue
to

practice
noticing
these
experiences
as
they
occur
in
the
present
moment
and
label
them.
The
next
step
is
to

remember
they
can
be
held
at
the
same
time,
lightly,
just
like
the
cards
in
the
bag.
Inform
clients
that
you
may
be

asking
them
to
write
down
more
internal
and
external
experiences
as
they
are
noticed
in
group.
These
may
be

placed
in
the
bag,
and
also
may
be
shared
or
kept
private.







A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 17


Defusing
from
the
Noise:

Living
With
Thoughts
and
Voices


Goals,
Purpose
and
Process
Suggestions
for
Sessions
4‐6

The
following
three
group
sessions
are
intended
to
target
the
core
process,
defusion.
The
overarching
goals
of

defusion
are:


1.
To
introduce
the
concept
of
the
mind,
and
that
verbal
processes
(thoughts,
hallucinations,
&
delusions)
are

produced
by
the
mind.




2.
To
learn
to
discriminate
thoughts
from
other
internal
experiences.


3.
To
teach
clients
that
verbal
processes
are
learned
from
the
time
we
acquire
language,
and
that
the
mind
is

trained
to
reproduce
verbal
material
and
accept
it
as
true.




The
Purpose
of
Defusion:
Addressing
the
Verbal
Network
in
the
Mind


The
purpose
of
cognitive
defusion
is
to
develop
a
different
relationship
to
one’s
verbal
processes
that
occur
in
the

mind—thoughts.
For
clients
experiencing
psychotic
symptoms,
defusion
targets
thoughts,
auditory
hallucinations,

and
delusions.

Defusion
for
these
clients
may
be
one
of
the
more
salient
processes
to
facilitate
behavioral

flexibility.



Thoughts, Hallucinations, & Delusions: 

From
the
moment
humans
begin
to
acquire
language,
their
mind
begins
developing
a
complex
verbal
network.

Verbal
relationships
to
stimuli
in
the
environment
are
learned,
and
they
stick
with
us
in
the
form
of
thoughts.

Ultimately,
instead
of
relying
on
the
environment
to
shape
reactions,
humans
inevitably
begin
to
react
to

thoughts
about
their
past
experiences.
This
process
allows
humans
to
plan
ahead
and
reflect
on
the
past,
but
also

has
a
down
side.
From
an
ACT
perspective,
attachment
and
reaction
to
thoughts
rather
than
to
one’s
current

experience
results
in
thought
mediated/rule
governed
behavior
instead
of
experience/contingency
mediated

behavior.
When
this
occurs,
we
end
up
reacting
to
thoughts
that
may
not
be
accurate
or
match
our
current

experience
in
life.
This
can
narrows
one’s
awareness
of,
and
limit
one’s
capacity
to
respond
effectively
to
their

present,
in‐the‐moment
environment.



Auditory
hallucinations
as
they
occur
in
psychotic
spectrum
disorders,
can
be
conceptualized
from
an
ACT

framework
as
thoughts
produced
by
the
mind
that
have
become
loud
and
externalized.
In
the
same
way
that

thoughts
are
often
inaccurate
representations
of
current
experience
slanted
by
our
verbal
network,
so
are

auditory
hallucinations.
Admittedly,
for
some
individuals
they
may
be
more
compelling
for
various
reasons

(externally
experienced,
attributed
to
famous/powerful
people,
etc.),
yet
they
are
thoughts.
The
degree
to
which

one
is
cognitively
fused
with
this
verbal
content
(thought)
is
another
way
of
saying
how
much
they
believe
the

content
to
be
true.
Once
fused
with
the
content,
behavior
starts
to
change
in
reaction
to
it.
From
an
ACT

perspective,
auditory
hallucinations
are
addressed
in
the
same
way
as
thoughts:
defusion.
This
allows
one
to

notice
the
hallucination/thought
without
attaching
to
or
reacting
to
the
content.


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 18


The
same
theory
of
cognitive
fusion
can
be
applied
to
delusions;
they
are
verbal
content
(thoughts)
to
which
the

client
is
attached,
believes,
which
then
drives
their
behavior.
Like
other
thoughts,
the
content
of
delusions
do
not

match
present
moment
experience.
Instead
the
content
may
have
a
paranoid
or
grandiose
quality
(i.e.
“The
CIA
is

watching
me”
or
“I’m
the
president
of
China”)
or
be
otherwise
distressing.
Again,
similar
to
AH,
the
degree
of

cognitive
fusion
to
the
delusional
though
is
identified
by
how
much
the
client
believes
it
to
be
true,
and
if
the
act

accordingly.
It
should
be
no
surprise
that
from
an
ACT
model,
delusions
are
addressed
in
a
similar
manner
as

hallucinations
and
thoughts,
via
defusion,
which
allows
one
to
notice
the
delusion/thought
without
attaching
to

or
acting
on
the
content.



The Result of Defusing 

Instead
of
accepting
thoughts,
hallucinations
and
delusions
as
factual
or
treating
them
as
bona
fide
external

stimuli,
defusion
helps
clients
appreciate
that
these
experiences
are
happening
in
the
mind;
and
that
the
mind

provides
constant,
innumerable
verbal
material.
Defusion
helps
the
client
create
some
distance
from
their

thoughts/hallucinations
so
they
have
more
room
for
choice‐‐whether
or
not
to
accept
and
react
to
the
verbal

content.
Also,
by
learning
to
watch
thoughts
from
a
distance,
the
client
begins
to
conceptualize
the
mind,
its

thoughts
and
hallucinations
as
being
ever‐changing,
less
real,
less
reliable,
and
ultimately
less
powerful
in

dictating
their
behavior.
Additionally,
learning
to
distance
from
verbal
content
becomes
an
alternative
to
trying
to

stop,
escape,
or
avoid
the
content;
saving
energy,
decreasing
distress,
and
allowing
for
more
flexible
behavior
in

the
presence
of
distressing
thoughts,
hallucinations
and
delusions.


Addressing
other
core
processes
in
defusion


Present
moment
focus
and
acceptance
are
two
core
processes
inherent
in
learning
to
defuse
from
thoughts
and

hallucinations.
Noticing
and
increasing
awareness
of
verbal
content
is
the
first
step
to
defusing
from
it.
Noticing

requires
being
present
to
what
is
happening
in
the
mind,
without
being
significantly
pulled
away
from
what
is

happening
in
one’s
current
experience
(i.e.
“I’m
noticing
my
mind
is
telling
me
‘I
can’t
do
this’,
while
I
am
sitting
in

the
group
looking
at
Dr.________
who
is
sitting
across
from
me).
The
process
of
noticing
the
verbal
content
also

requires
acceptance,
being
willing
to
have
it,
and
not
try
move
away
from
it.
Additionally,
noticing
verbal
content

often
brings
up
emotions
(i.e.
anxiety,
sadness).
Experiencing
(accepting)
these
emotions
versus
avoiding
them
is

an
added
aspect
of
increasing
awareness
of
verbal
processes.


Suggestions
for
group
process:
During
the
three
defusion
sessions
it’s
the
therapists’
task
to
aid
the
client
in

developing
a
different
concept
of
their
mind
and
of
their
thoughts.
Experiential
exercises
are
one
means
to

facilitate
this
by
aiding
clients
in
creating—in
the
present
moment—a
little
distance
from
their
thoughts.

Additionally,
direct
interventions
at
verbal
fusion
are
also
especially
effective.
These
can
occur
when
a
client
is

sharing
and
makes
a
statement
about
what
s/he
thinks,
believes,
or
basically
anything
other
than
an
expression
of

direct,
current
experience.



Some
examples
of
statements
evidencing
fusion
to
verbal
processes:



1.
“I
can’t….”;
“I
shouldn’t….”;
“I
must…”



2.
Telling
a
story
about
an
event.
This
occurs
when
you
find
yourself
listening
to
what
the
client’s
mind
is
saying

about
their
experience.
Some
verbal
content
may
match
their
emotional
experience
of
the
event,
and
some
may

not.
As
a
therapist,
you’ll
want
to
practice
defusion
in
your
own
mind
around
stories
shared
by
clients:
hold
the

verbal
information
lightly.



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 19


3.
Self‐statements
that
clients
share:
“I
am….”



4.
Delusional
content
and
material
that
becomes
tangential
(oftentimes
there
is
an
emotional
experience
that
the

person
is
trying
to
express
in
a
rush
of
"thoughts").


5.
Sharing
of
auditory
hallucinations/voices
as
if
they
are
real.
Alternately,
knowing
that
hallucinations
are
not

real,
but
are
a
symptom,
is
actually
a
move
towards
defusing
from
the
content.



Here
are
some
examples
of
in‐the‐moment
defusion
interventions
the
therapist
can
use
when
s/he
notices
fused

verbal
content.
These
are
intended
to
help
the
client
defuse
from
the
content,
and
in
some
situations,
connect

with
the
emotional
experience
behind
the
verbal
content.



1.
“So,
your
mind
is
saying….”


2.

“Thank
you
for
sharing
those
thoughts,
or
that
story.
I’m
wondering
what
feeling
you
had/have
that
prompted

you
to
share
those
thoughts;"
or
"What
did
it
feel
like
to
share
those
thoughts
w/the
group?"


3.

“Is
that
a
thought
you
have
often?”



4.
“How
long
has
your
mind
been
telling
you
that?”


5.
“Do
you
notice
your
mind
replaying
that
scenario/story
again
and
again?”


6.
“Whose
voice
is
that
in
your
mind?
It
seems
like
someone
might
have
told
you
that.
Is
that
true?”


7.
“Can
you
carry
that
voice
with
you,
like
a
radio
station
that’s
playing
in
the
background?”


8.
“Does
that
voice
talk
to
you
often?”



9.
When
the
client
is
sharing
a
lengthy
story
that
you
may
have
heard
before,
try
something
like,
“I’m
going
to

stop
you
for
a
minute,
is
that
okay?
I’m
just
noticing
that
this
is
a
story
in
your
life
you
return
to
often.
Do
you

notice
that
sharing
it
appears
to
take
you
away
from
the
group?”


10.
Use
of
metaphors
as
interventions
when
clients
are
sharing
fused
content:
(i.e.
Monkey
mind;
thoughts
as

pop‐ups
on
a
computer
screen;
thoughts
occurring
in
a
cartoon
‘bubble’
over
the
client’s
head;
thoughts
as

comments
from
your
co‐pilot—explained
later;
repetition
of
a
thought
‘milk;
milk;
milk’;
holding
thoughts
lightly

in
a
bag,
or
in
a
balloon,
carrying
them
throughout
the
day).
Once
the
client
is
familiar
with
some
of
these

metaphors,
you
can
begin
to
use
them
during
group.
For
example,
you
could
say
“sounds
like
that
monkey
is

swinging
in
your
mind
today”,
"you
co‐pilot
sure
has
a
lot
to
say
about
what
you
did,"
or
“do
you
notice
a
lot
of

scary
thoughts
popping
up
on
your
computer
screen
in
your
mind
today?”


You
may
come
up
with
your
own
ways
of
intervening
with
client’s
fused
verbal
material.
The
important
thing
is
to

be
consistent
with
these
interventions.
Repetition
is
important
in
behavior
therapy
to
reinforce
a
different
pattern

of
behavior
(in
this
case,
noticing
thoughts
as
thoughts).
If
you
continue
to
notice
clients’
patterns
of
fusion,
and

help
them
defuse
from
verbal
content,
they
will
learn
to
do
this
for
themselves.
Over
time,
the
goal
is

generalization
of
defusion.
You’ll
know
this
has
happened
when
the
client
is
able
to
notice
being
fused
with
a

thought
or
story
without
your
prompting.



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 20


Session
4:
Meeting
Your
Mind—The
Co‐Pilot

Purpose:
To
introduce
the
concept
of
the
mind
as
producing
verbal
material
(thoughts,
hallucinations,
and

delusions).


Prepare: No props needed for this session 

Orientation to group:
Ring
the
bell.



Briefly Review Last Session:  

Ask
clients
if
they
remember
what
we
did
last
session.
If
needed,
remind
them
that
we
noticed
internal

experiences
that
pull
us
away
(sometimes
totally
away)
from
being
present
in
the
group,
and
that
they
were

represented
by
walking
to
different
areas
&
writing
them
on
cards
to
put
in
our
bags.
Remind
them
that
the
last

three
sessions
have
been
focused
on
being
present.
Ask
again
how
it
might
be
useful
to
be
mentally
&
emotionally

present.
If
needed,
summarize
what
was
discussed
last
week
on
this
topic.


Group Introduction:


Slowly
pick
up
the
bell
and
hold
it
in
your
hand.
Explain
to
the
clients
we
ring
the
bell
at
the
beginning
of
each

group
as
an
invitation
to
focus
their
attention
and
be
"present."

Share
that
today
we’ll
be
looking
more
closely
at

our
internal
experiences,
particularly
our
thoughts
and
to
get
a
sense
of
how
attached
we
are
to
them.


Exercise
1:
Thoughts
about
the
Bell


Rationale:
At
this
juncture,
the
bell
has
been
used
three
times.
Clients
will
have
developed
some
thoughts
about

it.
These
thoughts
can
be
used
as
an
introduction
to
defusion
by
noticing
present
their
moment
internal

experiences
(their
response
to
the
bell),
and
experiencing
some
defusion
from
these
internal
experiences
by

verbally
labeling
them.


Step
1:
Place
the
bell
in
the
middle
of
the
group
and
ask
clients:
“Tell
me
what
you
think
about
this
bell
we
ring
at

the
beginning
at
each
session”.
Go
around
the
room
and
have
each
client
make
a
statement
about
the
bell.



Step
2:
As
they
share,
focus
on
distinguishing
the
types
of
experiences
they're
having
with
the
bell:





Thoughts—(i.e.
The
bell's
round
like
a
bowl,
I
think
this
is
a
stupid
exercise,…)
or
hallucinations‐‐voices.




Physical
Sensations
(i.e.
my
body
relaxes,
my
ears
tingle…).




Feelings/Emotions
(i.e.
I
feel
peaceful/calm,
or
feel
anxious…).



When
each
client
makes
a
statement,
follow
it
with
your
own
statement
emphasizing
the
type
of
experience
had.

At
the
end
of
the
sharing,
ask
clients
if
they’ve
noticed
the
group
member's
different
types
of
experiences.
Make
a

short
statement
describing
the
difference
between
thoughts,
physical
sensations,
and
feelings/emotions.
For

example:



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 21


“Many of you had thoughts about the bell—describing it, evaluating it, or stating what it reminds you of. Others 
had a physical reaction, their body responded in some way—relaxing, tingling, etc. Still other members had an 
emotional response. They felt peaceful, calm, or even anxious. These are internal experiences that we notice on the 
inside. 

Exercise
2:
The
Mind
as
a
Co‐pilot




Purpose 

The
purpose
of
this
exercise
is
to
introduce
the
concept
of
the
mind
as
producing
verbal
material.
The
concept
of

the
mind
will
begin
with
a
discussion
of
where
thoughts
originate
in
the
body.
Next,
a
metaphor
of
the
mind
as
a

co‐pilot
will
be
used
to
defuse
the
mind
and
its
verbal
processes
from
the
self.



Rationale  

In
order
to
effectively
target
defusion,
clients
need
to
be
able
to
talk
about
the
mind
as
producing
thoughts.
After

having
developed
this
concept,
thoughts
can
be
discussed
as
being
separate
from
the
individual,
and
additional

exercises
can
further
facilitate
defusion.



Step
1:

Follow
up
to
the
last
exercise
(Thoughts
about
the
Bell),
introduce
and
ask
clients
the
following
question:



Say something like, "We going to talk a bit about "thoughts"—one type of internal experience. A lot of you had 
thoughts about the bell.  Where in your body did the thoughts come from?”  

(Elicit
responses
from
clients)



“Could it be some people have the experience of thoughts being put into their head by a voice/hallucination, or 
some
other
way?
 

(Elicit
responses
from
clients)



"Is it true that our thoughts, basically any thought, even hallucinations happen pretty much automatically? For 
example, do we get to choose which thoughts pop into our mind?" 


(Elicit
responses
from
clients)



"How
does
this
happen?..."


Step
2:

At
this
juncture,
introduce
the
concept
of
the
mind
as
a
co‐pilot
with
the
following
suggested
script:



“Imagine that you are in an airplane, flying through life going different places. Every airplane has a pilot. Imagine 
that you are that pilot. You get to choose which direction to fly. As you may know, every plane also has a co‐pilot. 
Imagine the co‐pilot is your mind, where your thoughts come from. Just like pilots are taught to listen to their co‐
pilot and work together when flying a plane, we’re taught that the thoughts our mind has are important and 
should be  listen to as we go about life. Our co‐pilot or mind can be helpful in planning ahead for a flight, but he 
also can get pretty annoying. And, perhaps the most annoying part is that he’s always there, always with you. He 
never takes a holiday! 

A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 22


So, as you’re flying your airplane, your co‐pilot/mind keeps talking to you, chatting away about all kinds of things. 
Sometimes he makes comments about where you’re going, or judges you on how you're flying the plane. 
Sometimes his statements about you are so loud that it’s hard to pay attention to anything else, even flying.” 

Step
3:

Take
your
co‐pilot
(mind)
for
a
flight
(based
on
Taking
Your
Mind
for
a
Walk,
Hayes
et
al.
1999)





a.
Explain
that
today
you'd
like
each
group
member
to
take
a
flight
with
their
co‐pilot.




b.
Pair
group
members
up.




c.
Assign
each
member
of
the
pair
a
role—pilot
and
co‐pilot—and
explain
their
job:








Pilot:

choose
where
to
fly
(co‐pilot
follows),
DON'T
TALK,
allowing
your
co‐pilot
to
stay
with
you.







Co‐pilot:

walk
side
by
side
w/your
pilot,
TALK
NON‐STOP
to
your
pilot;
describing,
second
guessing,

judging,
wondering,
commenting
on
wherever
the
pilot
goes
and
whatever
you
imagine
the
pilot

is
seeing,
hearing,
thinking,
feeling…





d.
Model
how
this
is
done
with
a
client
or
the
other
therapist.





e.
Instruct
the
pilots
to
take
a
3‐4
minute
flight
(walk),
co‐pilots
right
beside
them.
Tell
them
to
take‐off
(you

may
invite
them
walk
around
the
room,
into
the
hall
or
other
convenient
areas).





f.
After
3‐5
minutes,
stop
the
action
&
instruct
clients
to
switch
roles—pilots
become
co‐pilots,
etc.








remind
them
of
tasks
for
their
role,

&
have
them
take
another
flight.





g.
After
another
3‐4
minutes
have
everyone
return
to
the
group
and
sit
down.


Group Closure: 

To
end
this
session,
have
a
discussion
about
clients’
co‐pilots.
While
there
may
not
be
time
to
facilitate
an
in‐
depth
conversation
about
each
client’s
mind,
the
therapist
should
spend
time
ensuring
that
each
client
has
the

concept
of
their
mind
being
separate
from
them
through
the
use
of
the
metaphor.
Asking
questions
about
clients’

co‐pilots
can
facilitate
this
process.
For
example,
what
is
your
co‐pilot
saying
to
you
now?
Do
you
ever
hear
your

co‐pilot
talk
out
loud?
Is
he
like
a
voice
talking
to
you?
Does
your
co‐pilot
distract
you
from
being
present
in
our

groups,
or
from
being
present
for
meaningful
life
events?
Does
your
co‐pilot
ever
try
to
control
the
direction

you’re
“flying”
in
life?
Note
that
we
will
be
returning
to
this
exercise
often
throughout
these
groups.




A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 23


Session
5:
Experiences
and
Thoughts

Purpose:
The
purpose
of
this
session
is
to
engage
clients
in
the
experience
of
eating
using
their
senses,
and
to

discriminate
sensory
experiences
from
thoughts
or
voices
about
those
experiences.
The
co‐pilot
metaphor
is

continued
in
this
session,
as
are
use
of
the
bags.


Prepare:


Bring
the
client’s
bags
that
they
used
in
the
2nd
session.


In
each
client’s
bag
place
something
edible
(common
foods):
a
piece
of
candy
(peppermint,
chocolate,
gum
etc.),
a

piece/slice
of
fruit
(grape,
apple,
orange),
or
a
slice
of
cheese,
cracker,
or
,

candy;
a
grape/raisins,

half
an
orange,

a
piece
of
gum,
etc.
(Be
creative,
a
mix
of
things
that
are
edible).


A
three
by
five
card
for
each
client.
On
one
side
of
the
card,
write:
“My
co‐pilot”
with
the
following
questions:



“When
I
see
this
food,
my
co‐pilot
says:___________________________________________________”


“When
I
smell
this
food,
my
co‐pilot
says:__________________________________________________”

“As
I
taste
this
food,
my
co‐pilot
says:_____________________________________________________”

Another
common
thought
about
this
food
is:_______________________________________________”


A
white
board
with
markers


Orientation to group:
Ring
the
bell.



Briefly Review Last Session:  

Ask
clients
if
they
remember
what
we
did
last
session.
If
needed,
remind
them
that
we
discussed
our
different

reactions
to
the
bell—physical
sensations,
emotions,
thoughts.
We
focused
on
one
of
the
more
constant
internal

experiences
we
all
have—Thoughts—and
looked
at
where
they
come
from
(our
mind
or
co‐pilot).
We
met
and

took
our
co‐pilot
for
a
brief
flight,
noticing
how
he's
chattering
away
all
the
time.

Make
sure
the
clients
have
the

concept
of
this
metaphor—the
pilot
is
separate
from
the
co‐pilot,
chooses
where
to
go;
&
the
co‐pilot

representing
their
mind
comes
up
will
all
sorts
of
comments
(thoughts)
about
this
and
other
things.



Group Introduction:  

Begin
by
telling
clients
that
today’s
group
will
be
about
using
our
senses,
while
also
listening
to
what
our
co‐pilot

says
about
that
experience.
Introduce
the
concept
that
when
we
have
a
sensory
experience
(like
taste,
smell,

sight)
thoughts
occur
in
our
mind
almost
simultaneously,
and
that
it’s
important
to
be
able
to
tell
one
from
the

other.
You
may
want
to
refer
to
the
fact
that
we
are
having
experiences
in
life
all
the
time,
so
we
sometimes

forget
that
thoughts
about
those
experiences
are
different
from
the
experience
itself.
If
clients
appear
confused
at

this
concept,
this
is
understandable.
The
concept
of
discriminating
thoughts
from
experiences
is
a
difficult
one

without
an
experiential
exercise
aimed
at
defusion.
That
is
the
purpose
of
this
session.




A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 24


Exercise
1:
Listening
to
Your
Co‐pilot:
The
Thoughts
He
Gives
Me


Rationale:  The
rationale
of
this
exercise
is
to
use
the
experience
of
eating
(using
the
senses)
to
practice
noticing

thoughts
while
having
an
experience.
The
common
sensory
experience
of
"taste"
is
used
(use
common,
well

known
foods,
so
that
clients
are
less
distracted
by
the
experience
and
more
able
to
notice
their
thoughts
about
it).

This
will
be
practice
for
later
exercises
in
acceptance
of
difficult
feelings.  

Step
1:

On
the
white
board
create
two
columns
with
the
headings:
Present
Experience
and
Thoughts.
As
you

move
through
the
sensory
experiences,
write
each
one
under
the
Present
Experience
column,
and
when
clients

share
their
thoughts
about
that
experience,
write
those
under
the
Thoughts
column.


Step
2:

Hand
out
the
bags
with
the
food
items
in
them
to
each
client.
Give
each
client
a
three
by
five
card
with

the
questions.


Step
3:
Have
the
clients
remove
the
food
item
from
their
bags
and
hold
it
so
others
can
see.
Tell
them
not
to
eat

the
food,
but
to
just
hold
it
for
now.



Immediately,
some
clients
may
begin
to
make
statements
such
as
“Oh yea, I got the chocolate”,
or
“man, I got the 
orange, wish I had the gum”.
As
clients
begin
to
make
statements
about
what
they
received,
state
that
you
notice

their
co‐pilots
are
pretty
active
and
cite
a
few
examples
you
heard.
Make
it
clear
that
the
statements
clients
are

saying
are
coming
from
their
minds
(their
co‐pilots).



Step
4:
Ask
clients
to
complete
the
sentence
for
“#1”
on
the
three
by
five
card.



Step
5:
Without
discussion,
move
to
asking
clients
to
smell
the
food
without
eating
it.
After
a
moment,
ask
the

clients
what
thoughts
their
co‐pilot
came
up
with
about
the
smell.
Remind
clients
that
this
can
include
thoughts

about
past
times
(childhood,
holidays,
etc.),
or
thoughts
about
the
current
experience.



Take a few minutes for clients to share what thoughts came up. 

Step
6:
Ask
clients
to
complete
the
sentence
for
“#2”
on
the
three
by
five
card.



Step
7:
Ask
clients
to
taste
the
food.



You
may
instruct
the
eating
of
food
items
as
a
mindful
eating
exercise.
Ask
clients
to
notice
the
way
the
food
feels

in
the
mouth,
chewing
slowly
and
paying
attention
to
what
it
feels
like
to
swallow
the
food
(when
they
are
unable

to
feel
the
food
in
their
throat).
You
are
bringing
clients
into
experiential
contact
with
eating.
At
the
same
time,

the
mind
will
be
providing
thoughts
about
this
new
way
to
eat.



Take a few minutes for clients to share what thoughts came up asking them what it was like to eat the food in this 
slower, more intentional manner. 
As
they
share
these
thoughts,
bring
their
attention
to
the
thoughts
as
more

material
provided
by
their
co‐pilot. 

Step
8:
Ask
clients
to
complete
the
sentence
for
“#3”
on
the
three
by
five
card.



Step
9:
At
this
time
ask
clients
to
consider
question
#4
on
the
three
by
five
card,
and
to
fill
in
the
blank.



Group Closure: 

A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 25


To
close
the
session,
have
a
discussion
about
the
exercise,
paying
attention
to
addressing
the
following
points:

You
can
introduce
this
discussion
by
saying
something
like,
“Today we tried to slow down the simple experience of 
eating a bit of food…”


1.
What
senses
were
involved?


2.
Specifically,
who
was
it
that
came
up
with
the
statements
written
on
your
card
(make
sure
the
clients

understand
that
their
mind/co‐pilot
provided
those
statements).



3.
How
long
did
it
take
for
your
co‐pilot
to
jump
into
gear
and
start
making
comments
to
you,
the
pilot?


4.
Where
does
your
co‐pilot
come
up
with
this
stuff?


5.
Look
at
your
response
to
question
#4.
Where
did
your
co‐pilot
get
this
information
(society,
family…)?



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 26


Session
6:
Training
Your
Co‐Pilot

Purpose:
The
goal
of
this
session
is
for
clients
to
realize
how
easily
and
quickly
the
mind
is
trained,
understand

that
it’s
trained
by
all
the
verbal
material
(historical
and
present)
in
our
environment,
and
experience
from
a
little

distance
some
of
the
verbal
material
their
mind
gives
them.

Metaphors
of
training
the
mind
and
“passengers
on
a

plane”
will
be
used.



Orientation to Group:



Prepare:

No
materials
needed


Ring
the
Bell



Briefly Review Last Session:  

Ask
clients
if
they
remember
what
we
did
last
session.
If
needed,
remind
them
that
we
had
an
experience
with

food
and
noticed
how
quickly
our
minds/co‐pilots
jumped
in
with
their
comments.
Make
sure
clients
are
aware

how
quickly
our
co‐pilots
give
us
thoughts
about
our
life
experiences—seemingly
at
the
same
moment
we
have

the
experience.


Introduction
to
the
Group:


Say
something
like,
“Last week we asked the question, ‘Where does your co‐pilot (mind) come up with his stuff?’ 
He seems to have an endless supply of material to say to you (the pilot).  Where does he get it? In today’s group 
we going to going to see where our co‐pilot gets his material, what he does with it, and experience this in an 
exercise.”




Exercise
1:

Our
Co‐pilot’s
Training:


Rationale:
The
purpose
of
this
brief
exercise
is
to
experience
how
easily
our
minds
are
trained
by
verbal
material

in
our
environment
and
how
well
our
minds
retain
that
information.


Step
1:

Invite
the
members
to
do
a
little
experiment
about
a
nursery
rhyme.
Ask
them
to
complete
this
sentence:

"Mary
had
a
little
_______."
You
can
sing
it
if
they
are
hesitating.
(If
they
don’t
know
this
rhyme,
ask
them
to

continue
this
letter
sequence,
“A,
B,
C,
___.”


Step
2:

After
the
clients
respond,
ask
them
the
following
questions:

Who is it that is remembering this rhyme?
(co‐pilot)

Who taught it to your co‐pilot, or where did he learn it? 
How long has it been since they heard this rhyme?
(Point
out
that
they
still
remember
it)


Say
something
like,
“Even as you do other activities today, your co‐pilot will keep this nursery rhyme it has learned 
from ______ (note their responses from the question above) stored away for later use. Similarly, as you have been 
flying through life, your co‐pilot has also learned ‘thoughts’ from other people in your live (i.e. family, friends, 
peers, doctors, etc.), and from the things people have produced (books, TV shows, movies, advertisements, etc.). 
Unfortunately, many of these thoughts may not be as nice as ‘Mary had a little________ (prompt them to fill in 

A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 27


the blank).’ We might even have these thoughts a lot more frequently than, ‘Mary had a little lamb’ making them 
very hard to change.”


Step
3:

Ask
clients
to
take
a
few
moments
and
remember
something
unkind
that
was
said
to
them
when
they

were
a
child
or
teenager.
Ask
for
volunteers
to
share
examples.


After
they
share,
say
something
like,
“As you’ve been living your life, those unkind statements have stuck in your 
mind. Your co‐pilot has stored those words for many, many years after you heard them, and even when you 
weren’t around the person who said them. Our co‐pilots are very skilled at learning and remembering verbal 
information, and they feed it back to us all the time!”  
 
Exercise
2:
Passengers
on
Your
Plane:


Rationale:

The
purpose
of
this
exercise
is
for
the
clients
to
experience
from
a
little
distance
(defusion)
their
mind

giving
them
thoughts.
The
key
here,
given
that
this
is
a
defusion
exercise,
is
to
illustrate
the
distance
clients
can

get
from
the
thoughts.
They
"have"
the
thoughts,
the
thoughts
don't
"have"
them.


Introduction:

Say
something
like.
“As we’ve mentioned, all our life people around us have been training our co‐
pilots. They may be our family members, people we met in grade school, at former jobs, our doctors (past and 
present), and even the people here at the PRRC. Sometimes, even society joins in with its messages. For example, 
“if you drink this beer, or lose weight, or buy this product you’ll be beautiful, successful and have a loving partner!  
Imagine that these people or messages you’ve encountered at different times in your life are like passengers on 
the airplane that you (the pilot) and your co‐pilot are flying. All day long, these passengers are giving directions 
and making comments to your co‐pilot, and your co‐pilot passes them on to you, sometimes adding his own 
comments. Sometimes they say the same things over and over. For example, your mother might be on the plane, 
telling the co‐pilot that you need to put your coat on because it’s cold outside (even if it’s summer!). Another 
passenger might be a voice (hallucination) you began hearing some years ago commenting about your life or 
telling your co‐pilot what you should or shouldn’t say. A lot of the information given to the co‐pilot doesn’t make 
much sense. But, as he gathers it, he’s repeating it to you.” 

Step
1:

Let
the
clients
know
we
are
going
to
do
another
exercise.
Begin
setting
up
the
chairs
for
the
exercise
(two

chairs
side
by
side
in
the
middle
of
the
group
for
the
pilot
&
co‐pilot,
with
three
chairs
right
behind
them).
State,

“We will be doing an exercise that uses ‘Mary had a Little _______’ (keep prompting) and some other things our 
co‐pilots have learned and tell us.”

Ask
for
a
volunteer:
“Who would like to take their co‐pilot for a flight today?”



Step
2:

Identify
3
passengers
that
are
on
the
volunteer’s
(pilot’s)
plane.
Ask
the
pilot
who
taught
them,
where,
or

how
they
learned
the
rhyme,
“Mary
had
a
little
______.”

This
person,
organization
(kindergarten),
or
TV
program

will
be
their
first
passenger.
Select
2
other
passengers
by
asking
the
pilot
to
identify
people
in
their
life,
messages

from
society,
or
maybe
even
voices
they
hear
that
have
expressed
annoying,
unkind,
or
scary
things
to
them.
If

this
is
difficult,
it
may
be
helpful
to
ask
the
pilot
if
he’s
“gotten
a
negative
message”
from
others/society
about
his

abilities
(physical
strength,
intelligence,
capability
to
work,
etc.),
his
appearance,
mental
condition,
or
health.
Ask

the
pilot
if
someone
gave
them
a
nickname
(oftentimes
there
is
an
unflattering
message
attached).
Specifically

identify
the
people
or
entities,
and
what
it
was
they
told/conveyed
to
the
pilot.


Step
3:

Choose
other
group
members
to
act‐out,
“be”
the
co‐pilot
and
passengers.
Designating
the
co‐therapist

as
the
co‐pilot
is
often
helpful.
Choose
3
clients
to
be
the
passengers.
Have
them
take
their
seats
on
the
plane.



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 28


Step
4:
With
the
information
just
gathered,
assign
to
each
passenger
the
person
or
entity
from
the
pilot’s
life
they

will
be
representing,
and
the
specific
“thought”
they
taught
the
co‐pilot
(i.e.
you
are
the
Sesame
Street
TV

program
that
taught
him
“Mary
had
a
little
_____,”
you
are
the
pilot’s
mother
&
you
taught
his
co‐pilot,
“You
will

never
succeed
at
anything,”
etc.).
Instruct
them
that
their
job
will
be
to
repeat
this
“thought”
to
the
co‐pilot
in

different
ways—loud,
soft,
close
(lean
forward),
far
away
(lean
back),
angrily,
sweetly,
etc.—when
the
pilot
begins

flying.



Step
5:
Instruct
the
co‐pilot
to
repeat
these
“thoughts”
to
the
pilot;
making
comments,
judgments,
or

observations
about
them;
and
adding
any
commentary
about
how
this
should
affect
the
flight
the
pilot’s
taking,
or

about
this
exercise.



Step
6:
Instruct
the
pilot
to
choose
a
destination
(state
this
out
loud),
take
the
wheel
of
his
plane
and
“take
off”

on
his
flight.
Instruct
the
passengers
and
co‐pilot
to
perform
their
roles,
coach
them
as
needed.




Step
7:
Repeat
this
exercise
with
1‐2
other
groups
of
clients
as
time
allows.



Discussion:
Several
possible
discussion
points
to
choose
from
are
provided
below:


1. What
was
it
like
trying
to
fly
the
plane?


2. How
long
have
your
passengers
been
on
the
plane?


3. Have
you
ever
tried
to
change
what
your
passenger
say?


4. Say
to
the
clients,
“Mary
had
a
little
_________
(prompt
them
to
fill
in
the
blank).”
Note
that
their
co‐
pilots
still
have
this
information.
How
hard
it
might
be
to
change
“lamb”
to
‘fish,”
and
never,
ever
think
of

lamb
again
when
you
heard
this
nursery
rhyme?

We
probably
would
find
it
hard
to
change.


5. Do
you
always
follow
through
with
what
your
co‐pilot
tells
you
to
do?
Ask
for
examples
where
they
didn’t

(I
should
eat
less
fried
food,
take
my
meds,
exercise,
etc.).

** This may be a useful time to discuss 
command hallucinations. Ask
which
passenger
on
the
plane
might
have
given
that
instruction
to
the
co‐
pilot.



6. Are
there
any
passengers
you
would
like
to
kick
off
the
plane?
Who
&
why?


7. What
things
have
you
tried
to
do
to
“get
rid
of”
your
passengers
on
your
plane?


8. Is
it
realistic
that,
if
you
were
told
something
by
your
mother/friend/family
member
20
years
ago,
and
it
is

still
with
you
that
you
can
get
them
off
your
plane?


9. How
might
it
be
useful
that
our
co‐pilot
so
easily
trained
(we
can
learn
things,
plan,
etc.)?
How
might
it

not
be
so
useful
(says
too
much,
keep
repeating
the
same
thing,
gives
inaccurate,
unhelpful
information,

etc.)?
Ask
for
examples.


10. Do
you
always
follow
through
with
what
your
co‐pilot
tells
you
to
do?
Ask
for
examples
where
they
didn’t

(I
should
eat
less
fried
food,
take
my
meds,
exercise,
etc.).

** This may be a useful time to discuss 
command hallucinations. Ask
which
passenger
on
the
plane
might
have
given
that
instruction
to
the
co‐
pilot.



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 29


Group Closure 

Any
of
the
discussions
points
above
may
close
the
group.
Leaving
some
ambiguity
about
whether
getting
rid
of

thoughts
actually
works,
is
okay
at
this
point.
Given
that
this
session
is
aimed
at
defusion
from
thoughts,
the
goal

is
not
to
facilitate
creative
hopelessness
about
getting
rid
of/changing
thoughts.
The
discussion
points
about
the

last
exercise
certainly
introduces
the
concept
of
unwanted
thoughts
and
asks
clients
to
question
whether
“taking

the
passengers
off
the
plane”
is
really
possible.



Remind
clients
that
they
can
ask
the
annoying
passengers
to
leave
their
airplane
at
any
time.
Suggest
that
they
try

that
this
week,
and
see
if
it
works.


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 30


A
Review
of
Acceptance:



Goals,
Purpose
and
Process
Suggestions
for
Sessions
7‐9

The
following
three
group
sessions
are
intended
to
target
the
core
process,
acceptance.
The
overarching
goals
of

acceptance
are:


1.
To
bring
clients
into
contact
with
the
experience
of
trying
to
push
away/get
rid
of
unwanted
thoughts
and

emotions
(i.e.
to
identify
the
process
of
experiential
avoidance).


2.
To
bring
clients
into
contact
with
the
unworkability/ineffectiveness
of
experiential
avoidance.


3.
To
introduce
acceptance
as
an
alternative
to
experiential
avoidane
behaviors.



The
Purpose
of
Acceptance:
Providing
a
Choice



From
an
ACT
perspective,
most
humans
identify
certain
thoughts
and
feelings
as
“bad”
and
others
as
“good”.
We

often
try
to
change,
ignore
or
stop
thoughts
identified
as
“bad,”
in
an
attempt
to
avoid
pain
and
increase
our

pleasure.
Over
time,
efforts
to
push
away/attempts
to
get
rid
of
unwanted
thoughts
and
feelings
often
become

automatic.
We
lose
awareness
that
we’re
engaging
in
behaviors
that
aim
to
suppress
“bad”
thoughts
and
feelings.

These
strategies,
termed
“experiential
avoidance”
in
ACT,
are
typically
ineffective
in
the
long
run,
and
seem
to
be

really
ineffective
with
the
thoughts
and
feelings
we
really
don’t
want
to
have.
They
also
require
a
lot
of
energy

(suppressing
unwanted
thoughts
and
emotions
is
hard
work);
energy
that
could
be
used
pursuing
more
flexible,

values‐based
behaviors.
Life
can
become
exhausting
and
narrow,
driven
mainly
by
rules
about
how
to
avoid
pain.

Through
this
avoidance
process,
typical
pain
that
is
a
part
of
life
morphs
into
intense
suffering.


This
may
be
especially
true
for
clients
with
severe
mental
illness,
such
as
psychotic
spectrum
disorders.
Clients

with
pervasive
symptoms
such
as
hallucinations,
delusions,
and
the
subsequent
psychosocial
impact,
experience

pain
in
multiple
areas
of
life.
They
may
have
little
awareness
of
how
their
attempts
to
escape
or
reduce
this
pain

snowballs
into
terrible
suffering.
One
likely
reason
for
this
is
because
efforts
to
reduce
pain
may
have
been

supported.
The
belief
that
one
needs
to
reduce
symptoms
in
order
to
improve
functioning
is
common
in
our

culture.
Additionally,
mental
health
practitioners,
family
members
and
others
may
have
emphasized
the
need
to

reduce
symptoms
in
hopes
this
will
provide
a
better
life
for
the
client.



ACT
provides
a
different
solution.
Instead
of
aiming
to
reduce
uncomfortable/painful
symptoms,
ACT
offers
clients

a
choice
in
the
option
of
acceptance.
Acceptance
via
ACT
is
not
resignation,
nor
is
it
passivity
in
the
presence
of

pain.
This
is
an
important
distinction.
Standing
with
oneself,
compassionately,
with
any
thoughts
or
feelings
that

arise,
is
acceptance.
When
individuals
have
operated
by
attempting
to
suppress
uncomfortable
thoughts
or

feelings
for
years,
there
may
be
a
lack
of
awareness
that
there
is
another
way
to
respond
to
personal
discomfort.

This
is
the
alternative
ACT
offers
clients.
From
this
framework,
when
an
uncomfortable/painful
thought
or
feeling


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 31


arises,
clients
can
say,
“I
have
a
choice
here,
I
can
respond
as
usual
and
struggle
to
push
this
thought
or
feeling

away,
or
I
can
stand
with
myself
and
have
it
and
continue
to
do
things
that
are
important
to
me.”


In
order
to
actualize
this
choice,
a
few
steps
are
necessary.
First,
there
must
be
an
awareness
of
the
thoughts
and

feelings
that
are
unwanted.
Second,
there
needs
to
be
a
recognition
and
identification
of
the
effort
and
ways
used

to
try
and
get
rid
of
the
uncomfortable
thoughts
and
feelings
(identifying
control
or
experiential
avoidance

strategies).
Third,
their
must
be
a
realization
that
these
avoidance
strategies
are
unworkable
(experienced

creative
hopelessness).
As
these
steps
occur,
the
option
of
acceptance
can
be
presented
and
perceived.
Clients

will
not
likely
grasp
onto
this
concept
with
enthusiasm
at
first.
In
fact,
resistance
to
the
concept
of
acceptance
as
a

choice
is
quite
common.
It
is
the
process
of
experiencing
acceptance,
while
releasing
their
grip
on
avoidance

strategies
that
eventually
teaches
clients
that
acceptance
provides
relief
from
suffering.



Addressing
other
Core
Processes
in
Acceptance


Contact
with
the
present
moment
and
defusion
from
thoughts
are
inherently
part
of
acceptance.
Accepting
one’s

internal
experience
requires
awareness
of
thoughts
and
feelings
as
they
are
occurring
in
the
present.
Intentional

awareness
of
thoughts
requires
a
degree
of
defusion,
given
that
one
is
distinguishing
them
as
separate
from
their

emotional,
physiological
and
interpersonal
experiences.

The
methods
used
to
suppress,
change
or
stop
certain

thoughts
or
feelings
are
generally
labeled
experiential
avoidance
and
move
one
away
from
the
present.

Acceptance
as
a
core
process
in
ACT
specifically
targets
the
reduction
of
experiential
avoidance
behaviors,

bringing
clients
in
greater
contact
with
their
present
moment
experience.



Similar
to
earlier
sessions,
it
will
be
important
for
the
orienting
therapist
to
help
clients
remain
in
the
present

moment.
Skills
taught
in
the
three
prior
defusion
sessions
are
incorporated
into
this
acceptance
section.
This

includes
continuing
the
metaphor
of
the
mind
as
a
co‐pilot
and
the
passengers
on
the
plane.
Up
to
this
point,
the

protocol
has
been
building
skills
for
how
to
accept
unwanted
thoughts
and
feelings
about
discrete,
current

experiences
(i.e.
notice,
label
the
experience,
and
defuse
from
thoughts
about
it).
The
following
three
sessions
will

integrate
these
skills
and
apply
them
to
unwanted
thoughts
and
feelings
arising
from
historical
experiences
that

clients
have
likely
attempted
to
avoid
for
a
long
time.
This
section
more
specifically
targets
experiential
avoidance

strategies
with
an
eye
towards
recognizing
their
ineffectiveness;
and
presents
the
vital
alternative
of
acceptance‐‐
the
choice
to
accept
unwanted
thoughts
and
feelings
by
noticing
them
for
what
they
are
(defusion)
and
staying

present.
Willingness
as
the
capital
for
developing
acceptance
is
also
introduced.



Suggestions
for
Group
Process


The
first
two
acceptance
sessions
are
devoted
to
increasing
clients’
awareness
of
unwanted
thoughts
and
feelings.

For
unwanted
thoughts,
the
concept
of
“thoughts
about
thoughts”
(sometimes
called
meta‐cognitive
processes)
is

introduced.
These
should
be
treated
the
same
as
other
thoughts,
using
the
metaphor
of
the
mind
as
co‐pilot.
For

example,
the
thought
“I
have
bad
thoughts,”
is
actually
just
another
thought
about
a
group
of
thoughts
that
the

mind
(co‐pilot)
is
labeling
as
“bad.”
Unwanted
feelings
that
co‐occur
with
certain
thoughts
can
be
tangled
with

meta‐cognitions
about
both
the
feeling
(i.e.
that
it
is
unwanted)
and
the
associated
thought
(that
it
also
is

unwanted).
For
example,
a
client
with
the
delusional
thought,
“there
are
cameras
in
the
ceiling,
so
it’s
dangerous

at
the
VA,”
may
feel
anxiety
associated
with
that
thought.
In
turn,
another
thought
“I
can’t
be
this
anxious,
it’s

killing
me,”
may
occur.
It’s
not
so
important
to
untangle
this
process
for
clients
in
these
sessions,
as
it
is
to
convey

the
concept
that
the
mind
(the
co‐pilot)
is
labeling
certain
thoughts
and
experiences
as
being
“bad,”
“intolerable,”

or
otherwise
unpleasant.
Discrimination
between
the
thought
or
feeling
being
bad,
and
the
mind
saying
that
it’s


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 32


bad,
is
an
important
distinction
and
continuation
of
defusion
that
needs
ongoing
emphasis
throughout
the

acceptance
sessions.


Another
crucial
facet
of
acceptance
is
increasing
client’s
awareness
of
their
experiential
avoidance
behaviors,
and

their
ultimate
ineffectiveness.
Central
to
this,
is
learning
to
discriminate
between
pain
(which
all
humans

experience)
and
suffering,
which
is
unnecessary
and
caused
by
attempts
to
avoid.
In
a
group
setting,
unlike

individual
therapy,
time
does
not
allow
for
a
comprehensive
clarification
of
each
client’s
full
range
of
EA

behaviors,
though
some
examples
might
emerge.
Instead,
an
experiential
exercise
showing
the
ineffectiveness
of

thought
suppression
and
changing
feeling
states
is
suggested.
The
point
is
to
make
sure
each
client
understands,

from
experience,
that
pushing
away
internal
experiences
is
futile
in
the
long
run.
Instead
of
selling
this
verbally
by

explaining
it,
we
suggest
group
exercises
and
metaphors
that
experientially
convey
it.


The
final
session
in
the
acceptance
section
uses
a
group
exercise
of
the
metaphor
“Tug
of
War
with
the
Monster.”

The
first
and
second
acceptance
sessions
build
toward
a
point
of
creative
hopelessness.
With
their
awareness
of

unwanted
thought
and
feelings,
and
a
recognition
of
the
futility
of
avoidance,
clients
are
in
a
position
to
seriously

consider
acceptance
as
an
alternative.
The
metaphor
of
dropping
the
rope
in
the
tug
of
war
with
the
monster
is

an
excellent
way
for
clients
to
experientially
sense
what
it
would
be
like
to
drop
their
struggle
with
unwanted

thoughts
via
EA
strategies
and
accept
them.



Clients
will
inevitably
show
resistance
to
this
idea.
Resistance
in
ACT
is
the
mind
creating
more
stories
about
how

to
escape,
even
how
to
escape
this
new
alternative.
Some
clients
may
show
resistance
by
apparently
“giving
up”

in
group
(i.e.
appearing
distracted,
checking
out),
being
quiet,
or
acting
out.
Some
clients
will
exhibit
confusion
to

the
idea,
and
may
in
fact
be
genuinely
confused.
The
idea
of
accepting
symptoms
that
previous
treatment

targeted
to
“get
rid
of”
is
confusing.
Therapists
may
find
themselves
just
as
perplexed.
We
suggest
the
therapist

practice
present
moment
focus
and
defusion
for
him/herself
by
noticing
the
confusion,
their
feelings
of
wanting

to
explain
the
concept
to
the
client
or
save
the
client,
their
thoughts
about
the
therapy,
or
themselves
as
a

therapist.




This
is
a
good
example
of
the
parallel
process
(here
with
creative
hopelessness)
that
often
happens
between
the

therapist
and
client
as
they
work
through
ACT’s
core
processes.
To
address
this
therapeutic
process
on
both
ends,

we
suggest
using
defusion
from
thoughts
about
the
process,
present
moment
focus
by
noticing
the
client’s

apparent
mood
state
(and
your
own
mood
and
thoughts)
and
leaning
in/accepting
all
that
shows
up
for
both
you

and
the
clients.


Finally,
when
targeting
acceptance
of
unwanted
experiences,
we
suggest
a
compassionate
stance
towards

yourself
and
your
clients.
Being
aware
of
the
universality
of
human
pain
engenders
compassion.
Although
the

clients
are
struggling
with
varying
content,
everyone
in
the
room
lives
with
painful
experiences
and
has
the
same

range
of
human
emotions
(i.e.
sadness,
anger,
anxiety,
disappointment,
etc).
We
all
have
made
some
attempt
to

move
away
from
these
thoughts
and
emotional
states
that
our
mind
says
are
“bad”
or
“unwanted.”
It
is
the

recognition
of
the
universality
of
these
experiences
that
arouses
compassion
for
oneself,
between
you
and
your

clients,
and
between
the
clients
in
the
group.
The
power
of
sharing
pain,
efforts
to
remove
pain,
and
the
difficulty

of
this
struggle
is
a
unique
benefit
to
conducting
ACT
in
group
format.
We
strongly
suggest
that
as
much
as

possible,
you
facilitate
discussion
between
clients
about
these
processes
and
exercises
have
been
included
to

encourage
peer‐to‐peer
interaction.


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 33


Session
7:
Unwanted
Thoughts

Purpose:
The
purpose
of
this
session
is
for
the
clients
to
become
more
aware
of
their
unpleasant
thoughts
and

voices
(hallucinations),
the
things
they
do
to
avoid
them
(experiential
avoidance),
the
utility
of
these
avoidance

attempts
(creative
hopelessness),
and
to
prepare
them
for
the
alternative—acceptance.


Prepare:

White
Board,
Clients’
Bags,
Pens,
Faux
reward?
(see
exercise
2),Cards
with
the
following
questions:





 1.
What
does
your
co‐pilot
say
that
feels
scary/anxious?



 2.
What
does
your
co‐pilot
say
that
feels
sad?


Orientation
to
Group:

Ring
the
Bell


Briefly
Review
Last
Session:


Ask
clients
if
they
remember
what
we
did
last
session.
If
needed
remind
them:
1)
our
minds/co‐pilots
are
very

skilled
at
learning
verbal
messages
from
people,
the
things
they
create
(nursery
rhymes,
advertisements,
TV

shows,
etc.),
and
even
voices
(hallucinations);
and
at
repeating
them
back
to
us.
Say,
“Mary
had
a
little
______

(prompt
members
to
complete
this
sentence—note
that
their
cp’s
still
remember
it).”
2)
These
people
and
their

creations
are
like
passengers
on
our
plane
that
repeat
messages
to
our
cp,
who
then
adds
other
comments
and

passes
it
all
on
to
us,
the
pilot.



Introduction
to
the
Group:


Say
something
like,
“Today
we’re
going
to
look
a
little
more
into
what
our
passenger
and
co‐pilot
tell
us.
Before

we
do…”
At
this
point
in
the
protocol,
it
may
be
helpful
to
get
a
“willingness
check”
with
the
group.
If
so
say

something
like,
“You’ve
probably
realized
that
in
this
group
we
ask
you
to
recognize
&
even
write
down
some
of

the
messages/thoughts
you
don’t
like
that
passengers
on
your
plane
and
your
cp
tell
you.
We
know
that
noticing

these
thoughts
is
uncomfortable,
because
it’s
also
uncomfortable
for
us.
I/we,
the
staff,
also
have
passengers
and

cp’s
that
give
us
messages/thoughts
we
don’t
like.
This
is
a
common
experience
for
everyone.
What
I
want
to

know
from
each
of
you,
on
a
scale
from
1
to
10,
is
how
willing
you
are
to
notice
and
have
for
a
while
some

uncomfortable
thoughts,
images,
&
feelings
so
we
can
continue
working
in
this
group?


A
‘1’
means
not
at
all,
a

‘10’
means
“bring
it
all
on.”

Sample
the
members.
Thank
those
with
high
willingness,
&
ask
those
on
the
low
end

if
they
might
be
willing
to
work
a
little
longer
to
see
it
if
might
be
worth
it.
If
still
unwilling,
note
that
the
focus
of

this
group
is
actually
about
the
effectiveness
of
this
stance,
&
invite
them
to
participate
as
they
would
like.



Exercise
1:
Getting
Rid
of
Thoughts


Rationale:
The
rationale
for
this
exercise
is
to
identify
methods
of
experiential
avoidance
of
thoughts
and
voices,

and
to
discuss
workability/ineffectiveness
of
thought
suppression.



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 34


Start
w/this‐‐Step
1:
Ask
clients,
“Last week you identified passengers on your plane that have taught your cp 
some
things
you
don’t
like—irritating,
lousy,

or
upsetting
messages/thoughts.
We
noted
that
these
passengers

might
be
people
or
societal
groups
from
your
past,
or
voices.
We suggested that that during this past week you 
ask some of these annoying passengers to leave your plane and take their irritating messages with them. Have any 
of you done this and tried to keep them off your plane? Has it worked?”   

(Elicit
Reactions
from
clients)



Step
2:
Ask
clients
to
raise
their
hands
if
they
believe
people
can
get
rid
of
unwanted
thoughts
or
voices

(hallucinations)—get
them
off
your
plane
for
good.
Say
something
like,
“It
makes
sense
that
we’d
try
to
get
rid
of

them.
First,
we
don’t
like
them,
and
second,
that’s
what
we’ve
learned
to
do.
Isn’t
it
true
that
with
physical
things

we
don’t
like
in
our
environment
or
with
us
we’re
pretty
good
at
tossing,
stopping,
or
changing
them
(give

examples
of
cars,
clothes,
hair
styles,
food,
medications).
If
we
don’t’
like
them,
we
get
rid
of
them,
and
it
works!

Are
thoughts/voices
different?


Step
3:
Invite
the
members
to
do
an
experiment
with
you
(based
on
Zettle’s
book).
Say
something
like:


1. Let’s
try
an
experiment
with
something
physical.
Let’s
suppose
that
you
don’t
like
the
décor
of
this
room—
the
chairs,
carpet,
pictures
and
paint.
Can
you
get
rid
of
them?
Will
you
if
I
pay
you?
(You
could
show
them

some
tangible
reward—money,
food,
etc.—and
keep
increasing
it
until
all/most
agree).


2. 
Now
let’s
consider
your
thoughts.
You
all
know
the
American
Flag?
Can
you
describe
it
to
me?

(Elicit
a

detailed
description)
Let’s
suppose
that
you
don’t
like
thinking
about
the
flag.
In
fact
you
hate
any
thoughts

about
it,
even
the
word
itself.
Can
you
get
rid
of
all
your
thoughts
about
it?
Can
you
not
think
about
it
for

the
next
12
hours?
Will
you
if
I
pay
you?
Let’s
try
a
few
minutes
(show
them
a
reward
&
test
them
for
a
few

minutes
by
waiting,
then
singing
“Oh
say
can
you
see...,”
saying
“red,
white,
blue”
and
“flying
at
half
mast.”



3. Ask
the
client’s
how
it’s
going
and
if
they’ve
been
able
to
not
think
about
it.
Then
ask
if
they
thought
about

it
just
for
a
split
second,
when
they
checked
to
see
if
they
hadn’t
thought
about
it.



4. Could
it
be
that
the
more
you
try
to
get
rid
of
a
thought
(to
get
a
big
reward,
or
because
we
really,
really

hate
it),
the
more
it
seems
your
cp
brings
it
up?


Step
4:

Ask
the
clients
what
they
have
tried
and
done
to
“get
rid
of”
irritating
thoughts
or
voices.
You
may
want

to
list
these
methods
on
a
white
board.
Discuss
their
relative
workability
and
cost/consequences
(i.e.
drinking

alcohol
may
block
thoughts
for
awhile,
but
it’s
bad
for
your
health
and

once
sober,
the
thoughts
return,
etc.).

Ask

how
well
these
things
have
worked
and/or
if
it’s
worth
the
cost.


Exercise
2:

What
is
Unwanted?




Rationale:  The
rationale
for
this
exercise
is
to
identify
the
nature
of
unwanted
thoughts
or
voices.
That
is,

thoughts
or
voices
become
unwanted
because
1)
Our
co‐pilot
labels
them
as
“bad”
or
provides
another
negative

verbal
evaluation
or,
2)
The
thought
or
voice
may
be
attached
to
an
unwanted
feeling
(i.e.
in
this
group
anxious

and
sad
will
be
two
emotions
used
in
an
exercise).
This
session
introduces
emotions
as
states
that
may
be

unwanted.
However,
the
focus
continues
to
be
on
acceptance
verses
experiential
avoidance
of
thoughts.


Step
1:

Ask
the
clients,
“Why
would
you
want
to
“get rid”
of
thoughts
or
‘kick passengers off your plane.’
What
is

it
about
some
thoughts
or
voices
that
makes
them
difficult
to
have,
or
unwanted?



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 35


Here you are introducing the idea that the mind has thoughts about thoughts and voices (labeling some as good, 
some as bad), and that feelings might be attached to thoughts and voices (i.e. “some thoughts that make me 
anxious”). 

You may want to write reasons on the white board, listing examples of “evaluative/judgmental thoughts about 
thoughts/voices, and emotions or physical sensations connected to thoughts/voices.” 

Step
2:


Ask
clients
if
they
can
agree
that
thoughts/voices
and
feelings
seem
to
go
together,
and
the
co‐pilot
may

have
thoughts
or
voices
about
those
feelings
(i.e.
a
voices
that
states
“you’re
weak
for
being
anxious”).


(Write the feelings “sad” and “anxious” on the white board, and ask clients “what does your co‐pilot say about 
these feelings”? Write down client responses.)  

Step
3:

Ask
clients
if
they
also
have
feelings
about
certain
thoughts/voices
(i.e. “does your co‐pilot ever tell you 
‘this thought makes you anxious’ or ‘This is a sad thought’ or ‘This is a threatening voice’)  

Remind clients that thoughts or voices and feelings can seem intertwined or one‐in‐the‐same. State that the next 
exercise will ask them to share some thoughts that seem connected to feeling sad or anxious.  

Exercise
2:
Meeting
One
Another’s
Co‐Pilots


Rationale:  The
rationale
for
this
exercise
is
for
clients
to
experience
sharing
unwanted
thoughts
or
voices
with

another
peer.
This
process
facilitates
exposure
to
the
unwanted
thought
and
the
unwanted
feeling.




Step
1:

Hand
out
the
cards
with
the
2
questions,
“What
does
your
co‐pilot
say
that
feels
scary/anxious?
&
What

does
your
co‐pilot
say
that
feels
sad?
“
Ask
clients
to
take
a
moment
&

answer
the
questions.


Step
2:

Split
the
clients
into
pairs
and
ask
them
to
take
4‐5
minutes
to
share
answers
to
the
questions
on
the

cards.
Provide
instructions
to
pretend
they
are
sharing
about
their
co‐pilot.
For
example:



“My
co‐pilot
has
told
me
that
I’m
worthless
for
a
very
long
time.”
Or
“It
feels
sad
when
my
co‐pilot
says
that
I’ll

never
get
better,
that
I’ll
always
have
schizophrenia.
Or
“My
voices
will
never
go
away.”



(It
is
often
helpful
to
model
this
first
either
with
your
co‐facilitator,
or
with
a
willing
client
volunteer).


Step
3:
Bring
clients
back
together
&
thank
them
for
participating
in
the
sharing
exercise.
Discuss
what
it
was
like

to
share
their
co‐pilot’s
thoughts
or
voices
that
are
scary
or
sad
with
another
person.



Exercise
3:





Step
1:
Ask
clients
to
place
their
cards
by
their
feet,
indicating
how
much
they
“want”
versus
“do not want”
the

thoughts/voices
listed
on
their
card
by
the
distance
the
card
is
from
their
feet
.
The
farther
away
they
place
their

card
from
their
feet
indicates
the
degree
to
which
they
do
not
want
to
have
the
thoughts
or
voices.



Step
2:
Ask
clients
to
raise
their
hand
if
these
particular
thoughts
or
voices
have
been
with
them
for:




 1.
More
than
one
month


 2.
More
than
one
year


 3.
More
than
5
years


 4.
More
than
10
years


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 36



 5.
More
than
20
years

Remind
them
that
the
struggle
to
get
rid
of
them
has
likely
also
been
ongoing
for
that
length
of
time.



Closure of Session:   

To
close
the
session,
ask
clients
to
look
at
the
cards
at
their
feet.
Ask
them
if
they
are
easily
able
to
read
the
cards

from
a
distance.
Ask
what
it
would
be
like
to
begin
to
see
the
unwanted
thoughts
at
a
distance,
just
as
they
are

written
on
the
cards.
Instead
of
being
held
tightly
by
their
co‐pilots
right
in
front
of
their
face.

The
thoughts
can

also
be
just
words
on
a
page
that
the
clients
can
see.
Ask
clients
to
pick
the
cards
up
and
hold
them
close,
and

then
move
them
farther
away,
at
an
arms‐length.
How
does
it
feel
to
move
the
card
closer
to
their
face?
Does
it

change
how
much
they
can
see
of
the
room,
the
others
members?



Finally,
ask
clients
to
add
the
card
to
their
bag.
Remind
clients
that
words
of
unwanted
thoughts
can
be
carried

lightly.



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 37


Session
8:
Unwanted
Feelings

Purpose:
The
purpose
of
this
session
is
to
continue
to
discuss
control/avoidance
strategies
with
regard
to

unwanted
emotions/feelings,
and
their
ineffectiveness.
Session
7
(unwanted
thoughts)
and
this
session
are

intended
to
target
experiential
avoidance
and
it’s
ineffectiveness,
and
prepare
the
group
members
to
consider

acceptance
as
an
alternative.




Prepare:

White
Board,
Client’s
bags
w/their
cards
from
the
last
several
sessions,
Large
cards
with
the
following

words
written
on
them:



Anxious

 Scared
 
 Sad
 Depressed
 Joyous
 


Excited


Disappointed


Peaceful


These
cards
should
be
posted
around
the
room,
visible
to
clients.
Each
card
should
be
equal
distance
apart.


Orientation
to
Group:

Ring
the
Bell


Briefly
Review
Last
Session:


Note
that
last
week
we
discussed
trying
to
get
irritating
passengers
off
our
plane.
Ask
if
any
clients
continued
this

week
to
push
away
upsetting
thoughts/voices—trying
to
kick
those
passengers
off
their
plane—and
what
they

tried.
Write
their
experiential
avoidance
strategies
on
the
white
board
&
discuss
their
workability/effectiveness
as

you
did
in
session
7.



Note
how
great
it
would
be
if
we
could
get
rid
of
these
upsetting
thoughts/voices
as
easily
as
we
can
get
rid
of
an

unwanted
chair
or
rug.
Ask
them
if
it
isn’t
true
that
the
more
we
don’t
want
to
have
some
upsetting
thought
or

voice,
the
more
we
seem
to
have
it?


Note
that
we
also
discussed
last
week
that
we
don’t
want
certain
thoughts
because
our
cp
tells
us
they’re
bad

(maybe
really
bad)
or
upsetting
feelings
are
attached
to
them.



Introduction
to
the
Group:


Explain
that,
“Today
we’re
going
to
look
at
how
people
not
only
try
to
get
rid
of
upsetting
thoughts,
but
also

upsetting
emotions/feelings
that
may
be
attached
to
them.”



Exercise
1:
Standing
with
Yourself


Rationale:


This
example
of
trying
to
move
away
from
feelings
may
seem
ridiculous
to
clients.
Of
course,
you’re

not
going
to
feel
differently
by
moving
farther
away
from
a
card
with
a
word
on
it.
However,
this
is
much
like

people’s
attempts
to
move
away
from
thoughts
about
feelings,
and
move
away
from
the
feeling
state.
It’s
futile.

The
simplicity
of
this
exercise
is
intended
to
convey
the
message
that
attempts
to
get
rid
of
feelings
and
thoughts

are
just
as
pointless
as
walking
away
from
a
card
and
expecting
change:
it’s
futile.
As
an
alternative,
clients
can

stand
where
they
are,
with
themselves,
accepting
the
thoughts
and
feelings
that
are
occurring.



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 38


Step
1:

Ask
clients
to
find
the
card
in
their
bag
that
they
wrote
the
thought
their
co‐pilot
gives
them
that
feels


scary
or
sad
(the
one
that
was
included
in
session
7
exercise
“Meeting
Your
Co‐Pilot”).
They’ll
likely
take
a
few

minutes,
sorting
through
the
cards.



Make a statement about how they are “looking for the thought”, is something like their  co‐pilot's pulling  things 
up to tell you, but that their actual co‐pilot gives them various thoughts all day instantaneously and doesn’t 
needing to “look for them” as they are now doing.  

Step
2:
Once
clients
have
found
this
card,
ask
them
to
read
(silently
to
themselves)
the
thought
on
the
card.



Say
something
like,
“On these cards you have written thoughts that your co‐pilot gives you; and these thoughts 
bring‐up emotions/feelings. Just like we try to get rid of upsetting thoughts/voices, isn’t it also true that we try to 
get rid of certain emotions/feelings…like being scared, anxious or sad?”


(Elicit
reactions
from
clients)



“People have a range of emotions, and some of them are uncomfortable. Our co‐pilot will tell us that some of 
them are “good” feelings and some of them are “bad” feelings. Let’s do an exercise about that.” 

Step
3:

Ask
clients
if
they
noticed
the
cards
posted
around
the
room.


Step
4:
Ask
the
clients
to
stand
up
and
walk
over
and
stand
next
to
the
card
that
best
describes
how
they’re

feeling
today.
Ask
them,
“What
does
your
cp
say
about
the
feeling
on
the
card
you’re
standing
next
to?
Ask
them

to
take
a
moment
and
decide,
“How
much
do
you
want
to
have
this
feeling
today?”



Step
5:
Tell
them,
“Now,
I
want
you
to
move
closer
to,
or
further
away
from
the
card
based
on
how
much
you

want
to
have
this
feeling.



Ask
them,
“Can
you
have
less
of
an
emotion/feeling
by
writing
the
name
of
it
on
a
card
and
walking
away
from
it?

Can
you
have
more
of
it
by
walking
towards
the
card?”
Instruct
the
clients
to
test
this
out
by
walking
further
away

from,
then
closer
towards
the
card
they
chose
to
stand
next
to.
(
*Note:
There
may
be
an
initial
change
in
their

emotional
state
related
to
walking
or
looking
at
an
emotion
written
on
a
card.
If
so,
wait
for
a
while
to
let
this

initial
reaction
subside,
then
ask
if
they
have
more
or
less
of
that
emotion.)


Ask
them,
“Can
you
change
your
emotion/feeling
to
something
else
by
walking
away
from
the
card
you
chose
to

stand
next
to
and
walk
toward
a
card
with
a
different
emotion
written
on
it?”
Instruct
the
clients
to
test
this
out

by
walking
towards
different
cards
and
seeing
if
their
emotions/feelings
change.
If
they
hesitate,
ask
one
of
the

clients,
“What
emotion
would
you
rather
feel?”
Then
have
them
walk
towards
the
card
labeled
with
their

response…this
could
get
a
bit
silly…if
so
you
can
ask
them
to
walk
towards
a
very
serious
card.


Step
6:
Have
the
clients
return
to
their
seats,
and
ask
them
to
share
the
results
of
these
experiments.
Were
they

able
to
change
the
how
much
they
felt
an
emotion
by
walking
further
away
from,
or
closer
to
its
name
written
on

a
card?
Were
they
able
to
get
rid
of
one
emotion
and
feel
another
by
walking
from
one
card
to
another?


Step
8:
Note
that,
“When
people
find
feelings
troubling
or
burdensome,
they
try
to
move
away
from
them
and
get

rid
of
them.”
Then
ask,
“Do
you
try
to
move
away
from
or
get
rid
of
unwanted
feelings
inside
yourself?”
“What
do

you
do?”
List
these
on
the
white
board.



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 39


Consider
suggesting:

1)
moving
residences
(to
Arizona…Ohio)
to
get
away
from
powerful
unwanted
emotions
or

thoughts/voices
(not
uncommon
for
people
with
SMI),
2)
staying
away
from
this
group‐‐
Maybe
some
members

are
not
so
happy
with
this
group
because
we
ask
you
to
have
thoughts
and
experience
feelings
that
you
don't
like.



Ask
the
clients
“Does
it
work?”
“Have
they
gone
away
;
have
you
gotten
rid
of
them?”


Share
with
the
group
the
saying,
“Where
ever
you
go,
there
you
are,”
and
ask,
“Don’t
your
feelings
and
thoughts

also
go
with
you?...aren’t
they
inside
you?”
“Can
you
move
away
from
something
that
is
inside
you?”
  


Elicit
comments
from
members


“So, here (on whiteboard) we have some examples of how you attempt to get rid of feelings, or move away from 
them. The problem, of course, is that you can’t just walk away from them as you walked away from these words 
on the wall. The feelings are inside of you, so they didn’t change when you walked closer to or farther away from 
the cards.  

So, when you try other things to move away from your feelings, isn’t it true that you’re walking away from 
yourself?” 

Closure
of
Session:


Discuss
the
concept
of
moving
away
from
feelings
and
thoughts
(i.e.
experiential
avoidance
strategies),
and
the

workability
of
this.
Elicit
examples
from
clients
about
their
experience
with
this.
Emphasize
that
moving
away

from
these
experiences
results
in
not
standing
with
yourself‐
abandoning
yourself.
At
the
end
of
the
session,

introduce
that
there
may
be
another
way.
The
following
question
may
be
used
to
close
the
group:





Say
something
like,
“What is compassion; what does this word mean? Take a brief moment and think of someone 
or some pet you loved, cared about.  If they hurt, what would you do?” 

“What if you decided to stand with yourself, like a compassionate friend, noticing all the thoughts your co‐pilots 
gives you, and being present for all the feelings you have? What would that be like?” 


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 40


Session
9:

Dropping
the
Rope—Willingness

Purpose:
 The
purpose
of
this
session
is
to
introduce
the
concept
of
acceptance
as
the
alternative
to
the
struggle

of
trying
to
escape
unwanted
experiences
(i.e.
experiential
avoidance).



Orientation
to
the
Group:

Ring
The
Bell


Briefly
Review
Last
Session/s:


*As
humans
we
have
all
sorts
of
thoughts
and
feelings


*We've
talked
about
how
when
we
get
up
in
the
am,
we
take
off
(like
in
a
plane)
flying
to
different
places,
and
we

have
a
co‐pilot
(our
mind)
talking
away
to
us
with
all
sorts
of
thoughts.
Some
of
these
thoughts
come
from
people

in
our
past,
the
media,
voices,
the
culture,
past
experiences
etc.


*We've
talked
about
we
may
not
like
some
of
these
thoughts
because
they
bring
up
uncomfortable
feelings…even

talked
about
how
this
group
might
be
difficult
because
as
we
talk
about
all
this,
some
uncomfortable
feelings

might
arise.



*Also
talked
about
how
we
try
to
get
rid
of
thoughts
our
cp’s
and
passengers
give
us
and
the
feelings
we
don't
like

(like
passengers
we
want
to
throw
off
our
plane)
and
how
this
doesn’t
really
work
very
well.


Introduction
to
the
Group:



Say
something
like,
“Over
the
past
few
days/week,
how
many
of
you
have
had
feelings
you
really
don't
like?
What

were
they?”

If
no
response
offer
a
few
possibilities…sadness,
anxiety,
depression…use
the
white
board.


Say
something
like,
“What
thoughts
are
connected
to
these
feelings?
“
List
them,
with
an
eye
towards
them
being

passengers;
write
them
on
the
white
board.


Say
something
like,
“Did
you
try
to
get
rid
of,
avoid,
push
them
away…What
did
you
try?
How
did
it
work?”
Write

these
control/avoidance
strategies
on
the
white
board.


Exercise:
Dropping
the
Rope
(Hayes

1987
&
1999)


Step
I:

Explain
that
you’d
like
to
do
an
exercise
about
what
we’ve
just
been
discussing.
As
if
someone
is
willing
to

help?

With
the
volunteer,
identify
s.t.
they
really
don't
want
to
experience
&
have
been
struggling
with
for
a
long

time
&
if
it
disappeared
they
believe
it
would
make
their
life
great.
Identify
the
emotion
they
have
around
what

would
happen
if
this
thing
grew/became
huge
(despair,
annihilation,
insanity,
terror,
unending
depression—this
is

the
pit
they
don't
want
to
fall
into).
Identify
the
thoughts
(passengers)
connected
to
this
unwanted
emotional

state.
Identify
what
they
have
tried
to
do
to
get
rid
of
the
thoughts
(possibly
some
connected
emotions)

associated
with
this.
Clarify
and
list
these
things
on
a
white
board.


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 41


Step
2:

Do
a
Tug
of
war:


A. Place
black
hole/pit
(drawn
on
a
large
poster
board
type
paper)
in
the
middle
of
the
room,
and
stretch
a

large
rope
across
the
pit
&
into
the
corners
of
the
room.


B. Have
the
client
volunteer
pick
up
the
rope
and
stand
close
to
the
edge
of
the
pit.
Identify
the
pit
as
the

unwanted
emotion
that
they
don’t
want
to
have
if
this
thing
grew/became
huge
(despair,
annihilation,

insanity,
terror,
unending
depression,
etc.)


C. 
Identify
one
of
the
more
powerful
thoughts
(passengers)
connected
to
the
unwanted
emotion
and
invite

another
group
member
to
represent
this
thought.
Have
them
stand
on
the
opposite
side
of
the
pit
from
the

volunteer,
pick
up
the
rope,
and
start
pulling
(somewhat
gently).
The
volunteer
will
likely
respond
by
pulling

back
to
avoid
being
tugged
into
the
pit.


D. 
Identify
one
of
the
things
the
volunteer
does
to
try
to
avoid,
change,
stop
the
thoughts
(above)
and
invite
a

different
group
member
to
represent
this
"control
strategy"
by
having
them
join
the
tug
of
war
on
the
side

of,
&
behind
the
volunteer.
Represent
other
unwanted
thoughts
and
control
strategies
by
having
other

group
members
and
join
the
tug
of
war
struggle.
*Ask
the
members
to
take
care
not
to
hurt
the
other

participants
by
not
pulling
too
hard
or
use
unbalancing
tricks,
and
note
that
this
is
what
we
might
try
in
life.



(Basically
the
tug
of
war
is:
co‐pilot
and
passengers
on
one
side
of
rope,
Pilot
and
control/avoidance

strategies
on
the
other
side
trying
not
to
get
pulled
into
some
horrible
emotional
abyss
the
volunteer
fears.)


E. As
the
tug
of
war
is
in
full
sway,
ask
the
client
who
volunteered
to
look
out
a
window
(if
available)
and
ask,

"What's
out
there?"
Or,
if
there's
no
window,
ask
him/her
to
notice
some
of
the
more
interesting
things
in

the
room…or
have
a
few
remaining
members
not
participating
in
the
tug
of
war
to
invite
the
volunteer
to
go

to
a
movie,
the
beach,
or
hang
out.

The
idea
is
to
pick
something
to
represent
life
that's
going
on
around

him
&
have
him
experience
his
unavailability
to
participate
because
he’s
focused
on
the
tug
of
war
struggle.


F. 
Briefly
highlight
the
experience
of
the
"struggle"
and
ask
the
volunteer
things
like:
“how
long
could
you
pull

on
this
rope
with
everyone
else
pulling
on
the
other
end?”
“Could
you
do
this
all
day,
all
year?”
“How
long

have
you
been
trying
to
pull
unwanted
thoughts/feelings
into
a
bottomless
pit
and
get
rid
of
them…,
a

Month,
a
year,
2‐3‐5‐10
years??”
“Is
it
tiring,
take
a
lot
of
energy?”

Finally
as
him/her
(and
the
group)
are

there
any
other
options?
i.e.
drop
the
rope.


Accentuation
Options:

1)
Use
name
tags
to
identify
the
control
strategies
and
the
unwanted
thoughts
as

"passengers
on
the
plane."

Or,
depending
on
the
client’s
willingness
to
share,
you
could
be
more
or
less
specific

about
the
nature
of
the
unwanted
thoughts
and
feelings.

2)
When
client
volunteer
drops
the
rope,
every
few

moments
offer
it
to
him
again;
if
he
takes
it
start
pulling
gently.
3)
When
the
client
volunteer
drops
the
rope,
have

the
other
participants
just
wander
around
the
room…still
being
present.
4)
During
the
discussion
with
the
group

about
the
exercise,
if
anyone
starts
to
describe
control
strategies,
walk
over
and
offer
them
the
rope;
if
they
take

it
start
pulling
gently
and
see
if
they
pull
back.
If
they
do,
you
could
start
another
brief
tug
of
war.




Depending
on
the
time,
you
could
do
this
exercise
a
few
times,
with
a
few
different
clients
and
then
bring
the

group
together
for
a
discussion.



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 42


Discussion
points:
Identify
the
experience
of
the
struggle—how
much
they
didn't
want
to
go
into
the
pit/how

much
they
wanted
to
get
rid
of
their
unwanted
thoughts
by
pulling
them
into
the
pit
or
pushing
them
away

somehow.
Ask
the
group
to
consider
what
comes
up
when
considering
dropping
the
rope.
How
often,
how
long

do
they
stay
in
their
struggle.
What
happens
to
the
rest
of
their
life
when
they
stay
in
this
tug
of
war
struggle.

What
about
the
concept/idea
of
acceptance?




The
suggestion
for
how
to
accept
would
be
to
end
the
struggle
by
dropping
the
rope
and
letting
the
passengers

and
the
co‐pilot
“be
in
the
room”
with
the
client.
You
could
even
suggest
that
there
might
be
peers
or
maybe
the

therapist
that
the
client
wishes
would
leave
the
group
sometimes,
but
they
attend
the
group
anyway.
The
idea

would
be
to
convey
that
dropping
the
rope
and
standing
with
the
thoughts
and
feelings
is
acceptance.



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 43


Session
9b:
Noticing
Your
Personal
Tug‐of‐War
(optional
session)

Purpose:

The
purpose
of
this
session
is
to
experience
more
fully
the
struggle
of
trying
to
escape
unwanted

experience
(i.e.
experiential
avoidance),
the
ways
we
try
to
do
this
(control
strategies),
and
a
workable
alternative

(acceptance).
Using
this
backdrop,
the
concept
of
the
observing
self
(self
as
context)
is
also
introduced.



**Bring
in
the
picture
of
the
hole/pit
used
last
week
&
before
starting
group,
place
it
in
the
center
of
the
room



Orientation
to
Group:

Ring
The
Bell


Prepare:

Bring
the
white
board,
Post‐its
for
each
member
with
a
hole/pit
draw
on
it
(maybe
hand
these
out
at
the

end
of
the
last
group?),
20
inch
long
strong
(but
relatively
small)
ropes/cords
for
each
member.


Briefly
Review
Last
Session:


Draw
the
groups
attention
to
the
hole/pit
it
the
center
of
the
room.
If
they
don't
recall,
remind
them
that
we
used

it
last
week
and
ask
them
what
it
represents
(if
needed
review
a
little
more
of
the
tug
of
war
exercise).
As
they

come
up
with
the
concept,
write
"Feeling
I
Don't
Want:"
on
a
white
board
at
the
top
of
column
1.
If
needed

remind
the
members
that
in
the
exercise
we
had
people
on
opposite
sides
of
the
pit
pulling
on
a
rope
against
each

other.
Ask
them
what
the
people
represent.
As
they
recall
the
concepts
write
"What
My
Copilot
Says"
and
"What
I

do
to
avoid,"
as
headers
in
columns
2
&
3
respectively.




Introduction
to
the
Group:



Say
something
like,
“We all have powerful/strong experiences (emotions, physical sensations, etc) that we don't 
want to have. Our co‐pilots often say things that bring up or contribute to these feelings. We try a lot of things to 
avoid, lessen or stop them and often end up in a struggle with them.” Ask
the
members
to
"think about your life 
for a moment and see if this is true for you…. As we mentioned last time, coming to this group may itself become a 
struggle since as we talk about unwanted thoughts/feelings they often come up. Check to see if sometimes this is 
case for you.” 

Exercise:
Your
own
personal
tug‐of‐war:


Rationale:
The
objective
of
this
exercise
is
to
have
each
client
identify
and
verbalize
what
emotion/sensation
they

don't
want
to
have,
what
their
mind
says
that
evokes/enhances
this
feeling,
and
what
they
do
to
try
and
control

these
experiences.


Step
1:

Show
the
post‐its
to
the
group
and
say
something
like,
"Today we're each going to get our own black pit… 
As we hand it out, we'd like to know from you what feeling or sensation it represents for you that you really don’t 
want to have." You
could
also
say
something
like,
"This might be different for each of us, but for nearly all of us it 
is something that we think is ruining our life, or if it magically disappeared our life would be great."

Slowly
hand

out
the
post‐its
to
each
member
AND
while
doing
this
ask
them
individually
what
emotion/sensation
they
really


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 44


don’t
want,
try
to
avoid,
move
away
from,
fight
against
or
get
rid
of;
one
that
is
really
scary
for
them.
Have
the
co‐
leader
write
their
responses
under
column
1.

If
they
struggle,
notice
this
and
note
that
you're
asking
them
to
do

something
that's
quite
difficult,
that
something
must
not
have
been
working
so
well
in
their
life
that
led
them
to

join
this
program/group,
and
that
they
might
have
some
strong
feelings
about
this
etc.
Ask
them
to
take
a
few

minutes
and
notice
this,
and
that
you'll
come
back
to
them.
and
While
handing
out
post‐its
with
a
black
pit
on

them
to
each
member,
explain
that
we're
going
to
do
a
little
different
version
of
the
tug
of
war
exercise
we
did

last
week‐‐that
this
will
be
your
own
personal
tug
of
war
exercise.

State
something
like,
"As
we
just
discussed,

this
pit
represents
some
emotion
or
sensation
that
you
really
don't
want
to
have
or
experience.
This
might
be

different
for
each
of
us,
but
for
nearly
all
of
us
it
is
something
that
we
think
might
really
ruin
our
life
or
if
it
were

gone
our
life
would
be
great."

As
the
group
members
what
are
the
emotions/sensations
they
really
try
to
avoid,

move
away
from,
fight
against
or
get
rid
of;
ones
that
are
really
scary
for
them
(if
they
have
difficulty,
offer
a
few

common
ones
"depressed,
overwhelmed,
out
of
control—crazy).
Try
to
elicit
from
each
member
and
help
them

clarify
what's
the
emotional
pit
that
they
really
fear,
and
list
these
on
the
white
board,
column
1.


Help
define
their
unwanted
feeling,
identify
thoughts
as
comments
their
copilot
might
say
and
ask
what
feeling

that
thought
might
bring
up.


Step
2:

Ask
the
group
members
what
their
co‐pilots
say
about
their
personal
pit—the
emotion/sensation
they

really
want
to
avoid.
Again,
try
to
enlist
each
member
and
write
down
their
responses
in
column
2.


Step
3:

Ask
members
to
identify
at
least
one
thing
they
do
to
try
to
avoid,
change,
stop
the
what
they
hearing

from
their
copilot
(above)
or
any
associated
feelings.
Try
to
enlist
each
member
and
write
down
their
responses
in

column
3.



Step
4:

Have
a
volunteer
come
up
and
stand
by
the
pit
on
the
floor.
Explain
that
we're
going
to
show
how
the

personal
tug
of
war
exercise
works.
Place
his
post‐it
pit
on
his
shirt
over
his
stomach.
Ask
him
what
his
pit

represents.
Give
him
the
small
rope
and
ask
him
to
hold
it
with
both
hands
about
6
inches
apart.
Explain
that
his

Lf
hand
and
fingers
represent
all
the
things
his
copilot
says
that
pull
him
close
to
his
pit;
and
that
his
right
hand
&

fingers
represent
him,
the
pilot,
and
all
the
things
he
does
to
try
and
avoid/get
rid
of
what
his
copilot
is
saying.

Have
him
share
what
his
copilot
says.
Have
him
start
a
mini
tug
of
war
over
the
post‐it
pit
on
his
stomach.
(you

could
label
each
of
his
fingers
on
his
left
hand
as
specific
comments
his
copilot
makes
&
those
on
his
right
hand
a

specific
thing
he
does
to
avoid/stop
those
copilot
statements).
Give
ropes
to
all
the
members
and
have
them

identify
what
the
different
elements
represent
for
them
(have
them
state
this
out
loud
as
you
give
him/her
the

rope),
and
start
their
own
tug
of
war.
(You
could
ask
them
what
different
fingers
represents
for
them
as
they

struggle).




Step
5:

Like
last
week
ask
them
how
this
tug
of
war/struggle
is
going.
Who's
winning?
How
long
have
they
been

at
it.
Is
there
an
alternative
to
staying
in
the
struggle.
Have
them
drop
their
rope,
then
pick
it
up.
Do
this
a
few

times.
Ask
them
if
they
do
this
tug
of
war
struggle
in
their
life.
Can
they
can
notice
the
different
pieces
of
this

struggle
in
their
life‐‐the
pit,
the
copilot's
comments,
the
things
they
do
to
avoid?


Step
6:

State
that
you
have
an
unusual
somewhat
odd,
but
important
question
for
them,
"Who
it
is
that
is

noticing
these
things—the
emotion
you
don't
want
to
have,
the
things
your
copilot
says,
and
what
you
do
to
try
to

avoid/get
rid
of
them?"
Briefly
discuss
their
responses,
then…


Ask
the
members
to
take
a
deep
breath,
close
their
eyes
if
that's
comfortable
for
them
and
ask
them
to
remember

a
day
or
moment
when
they
didn't
have
this
struggle,
maybe
recently
or
a
long
time
ago
when
they
were
young;

A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 45


perhaps
as
a
child.
Have
them
raise
their
hand
a
little
when
they
find
this
moment.
After
a
few
minutes
(not

everyone
needs
to
find
this
moment),
as
a
few
of
them
to
share
what
was
happening
in
their
life
at
that
moment

in
time.
Note
that
your
are
going
to
ask
this
odd
question
again…who
is
it
that
is
noticing
this
moment?
Or,
if
they

couldn't
find
one,
who
it
is
that
tried
and
noticed
they
couldn't
find
one?
Ask
if
they
can
notice
that
they
found

this
moment
of
not
struggling
(or
not)
and
that
they
can
also
notice
that
they
just
did
a
tug
of
war
struggle
with

unwanted
thoughts/feelings
a
few
moments
ago.


Ask
who
is
noticing
this
past
time
in
their
life
&
noticing
now

today
when
they
did
this
exercise
of
their
struggle?


Introduce
the
concept
of
the
observing
self—there
is
a
CONSTANT
YOU
that
notices/observes
things
all
the
time.

It's
the
same
YOU
that
can
notice
the
parts
of
the
tug
of
war
you
did
today,
as
the
YOU
who
remembered
a

day/moment
you
didn't
have
this
struggle,
or
the
YOU
that
looked
for
and
noticed
you
couldn't
find
a
day
w/o
the

struggle.
This
YOU
is
the
pilot
who
takes
off
each
day
and
flies
in
some
direction.



You
may
wonder
why
it's
important
to
notice
this
observing
CONSTANT
YOU,
this
activity
your
pilot
does.
Having

an
observing
YOU
(observing
pilot)
creates
options
for
choice...
By
YOU
noticing
the
tug
of
war
struggle,
it
gives

you
choice
to
hold
onto
the
rope
or
drop
the
rope,
to
pick
it
up
again,
to
drop
it...etc.
It
can
be
scary
to
consider

having
unpleasant
emotions
or
not
fighting
with
our
copilot
about
what
he
says,
but
by
noticing
you
may
see

acceptance
as
a
new
choice
that
may
lessen
suffering;
even
if
it
is
one
that
is
very
hard
to
make.



This
may
sound
like
another
kind
of
odd
request,
but
we
want
you
to
take
the
ropes
(they
are
yours)
and
carry

them
with
you
in
your
pocket/purse
this
week—noticing
that
the
opportunity
(rope)
for
the
struggle
is
always

there,
and
noticing
that
you
are
noticing
this.



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 46


A
Review
of
Self
as
Context:



Goals,
Purpose
and
Process
Suggestions
for
Sessions
10‐12

The
following
three
group
sessions
are
intended
to
target
the
core
process,
self
as
context.
The
overarching
goals

of
self
as
context
are:


1.

For
clients
to
become
aware
of
the
self
as
content
(content
you),
and
that
the
“content
you”
(thoughts
of,
“I

like
______,
I
am
a
______”
etc.)
changes
over
time
and
situations
as
do
feelings,
physical
sensations,
and
other

thoughts—they
are
impermanent.


2.
For
clients
to
become
aware
of
the
self
as
constant
(constant
you)
and
that
the
“constant
you”
does
not
change

over
time—it
is
permanent.




3.

For
clients
to
develop
increased
willingness
to
experience/accept
(rather
than
avoid)
feelings
and
to
defuse

(rather
than
fuse)
to
thoughts
based
on
an
increased
realization
of
the
impermanence
of
experiences
(goal
#1),

and
the
permanence
of
self
(constant
you‐‐goal
#2).
Through
this,
clients
will
become
more
flexible
in
their

response
to
unwanted
experiences
and
better
able
to
pursue
meaningful
activities.




The
Purpose
of
Self
as
Context




At
this
point
in
the
ACT
protocol,
thoughts,
voices,
feelings
and
physical
sensations
have
been
identified
as

experiences
to
be
aware
of
via
present
moment
focus.
Defusion
has
been
introduced
and
experienced
as
a
tool
to

notice
thoughts
and
voices,
and
create
a
little
distance
from
them.
Acceptance
has
also
been
introduced
as
an

alternative
to
using
ineffective,
costly
avoidance
strategies
to
deal
with
unwanted
experiences.
Self
as
context

(the
constant
you)
provides
the
basis
for
adopting
acceptance
as
a
way
of
approaching
life.

Awareness
of
and

experiencing
this
constant,
permanent
self
enables
one
to
hold
thoughts
and
voices
lightly,
and
experience

emotions
(even
painful
ones)
more
fully.
Knowing
that
there
is
a
constant
self
that
persists
and
survives
even
the

most
difficult
experiences
engenders
confidence
to
this
life
stance.


Self
as
context
is
the
“constant
you,”
the
perspective
from
which
speaking,
perceiving,
feeling,
acting
and
living

are
done
(Luoma
&
Hayes,
2006).
The
purpose
for
becoming
aware
of
the
“constant
you”
is
to
enable
one
to
let

go
of
the
conceptualized
sense
of
self
(content
you),
which
developed
through
language
and
experience.
From
an

early
age
humans
begin
to
identify
themselves
with
labels
(“I’m
a
girl,
I’m
five
years
old”).
As
more
language
is

acquired
we
develop
explanations
for
our
behavior
(“I
did
this
because…”),
and
stories
about
our
lives
(“I
could

never
do
that,
because…”).
The
“content
you”
encompasses
how
you
describe
yourself
and
all
of
the
associated

thoughts,
feelings
and
behaviors
that
tag
along.
While
building
a
content
you
is
effective
for
living,
describing
and

understanding
who
we
are
in
the
world;
it
can
become
limiting,
ineffective
and
problematic.
When
behavior
is

governed
by
constricting
or
numerous
rules
in
order
to
fit
a
narrowly
defined
content
you,
behavioral
flexibility

decreases,
and
operating
in
the
world
becomes
difficult.
For
example,
a
person
with
a
psychotic
disorder
may
be

fused
with
the
“content
you”
definition
“I am a psychiatric patient”.
If
that
person’s
behavior
is
governed
by
this

definition,
they
may
limit
their
activities
to
only
those
of
a
psych
patient
(taking
meds,
going
to
treatment,
etc.)

A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 47


and
not
even
attempt
other
activities
that
they
may
find
meaningful.
They
may
also
adopt
stigmatizing
self‐
judgments
perpetuated
by
society.


Experiencing
life
events,
notices
them,
and
notices
your
reaction
to
them.


The
“constant
you”
is
the
aspect
of
you
that
experiences
life
events,
notices
them,
and
notices
your
reaction
to

them.
The
constant
you
recalls
your
yesterday,
last
month,
or
10
years
ago.
It
is
the
constant
you
who
is
reflecting

and
observes
your
reaction
to
those
events
in
the
past.
It
is
from
the
perspective
of
the
constant
you
that
one

notices
“I’m
feeling
sad”
or
“I’m
having
the
thought
that
I
might
never
work
again,”
and
the
same
constant
you

observes
your
acceptance
or
avoidance;
fusion
or
defusion
to
those
experiences.



The
constant
you
observes
the
myriad
of
thoughts
and
feelings,
which
are
ever‐changing,
situationally
dependent

and
impermanent.
Being
in
contact
with
your
constant
you
theoretically
increases
willingness
to
accept

uncomfortable
and
unwanted
thoughts
and
feelings
by
providing
a
stable
base
from
which
to
experience,
and
a

reference
point
from
which
we
know
from
experience
that
sadness
gives
way
to
joy,
and
scary
thoughts
give
way

to
comforting
ones.



Addressing
other
Core
Processes
in
Self
as
Context


Present
moment
focus,
defusion
and
acceptance
all
facilitate
awareness
of
the
self
as
context.
In
order
to
connect

with
the
“constant
you”
who
is
experiencing
and
observing,
two
processes
must
first
occur
1)
one
must
be
in
the

present
moment
with
thoughts,
hallucinations,
feelings
and
physical
sensations,
and
2)
be
willing
to
have
those

experiences
(versus
avoiding
them)
via
defusion
and
acceptance.
To
this
end,
the
same
skills
used
to
enhance

present
moment
focus,
defusion
and
acceptance
should
be
continued
in
the
self
as
context
sessions.



Suggestions
for
Group
Process


The
concept
of
self
as
context
is
based
on
a
complicated
theory
of
mind
and
language
(i.e.
RFT).
In
depth

discussions
of
it
have
little
clinical
utility
in
therapy
sessions.
Therapists
need
to
watch
for
the
pull
to
explain
it
to

clients,
as
well
as
the
pull
to
better
understand
the
concept
themselves.
Experiential
understanding
of
self
as

context
is
the
more
powerful
means
of
conveying
the
concept.
Use
of
metaphors
and
experiential
exercises
is

especially
effective
for
this.
When
clients
are
confused
about
this
concept,
the
therapist
can
use
the
experience
of

noticing
that
one
is
confused
as
way
to
help
them
connect
with
their
observing,
constant
self
(constant
you).
In

short,
any
experience
the
client
has
and
notices
in
these
sessions
may
be
used
as
an
experiential
illustration
of
self

as
context:
There
is
a
“CONSTANT
YOU”
who
is
noticing
your
experiences
in
the
group
today.



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 48


Session
10:
I
Am
the
Person
Who…


Purpose:
The
main
purpose
of
this
session
is
to
connect
with
the
“self
as
content”
(content
you).
This
includes

noticing
and
identifying
the
various
opinions,
roles,
etc.
we
have
acquired
throughout
life
(i.e.
I
like
soccer,
R
&
B

music;
I
am
a
son,
a
client,
a
mechanic…).
Second,
this
session
introduces
the
“self
as
constant”
(constant
you)
by

noticing
feelings
about
“content
you”
”
(i.e.
I
notice
feeling
sadness/loss
over
what
“I
am
not”),
and
defusion
from

“content
you”
(i.e.
I
notice
judgments
about
self
that
my
co‐pilot/mind
is
providing).


Prepare:
Clients
bags,
Cards
(3x5)
with
the
following
stems
printed
on
them:



I
like:
____________________________

I
dislike:
__________________________


I
am
a:

1._________________________________

2._________________________________

I
am
not
a:

1.
__________________________________

2.__________________________________


I
used
to
be
a:

__________________________________

I
want
to
be
a:
__________________________________


Ring
the
Bell


Review & Introduction to Session:  

Begin
the
session
by
reminding
clients
that
the
last
couple
of
sessions
were
spent
discussing
unwanted
thoughts

and
feelings,
the
various
ways
of
trying
to
get
rid
of
them,
and
how
we
were
unsuccessful.
Acceptance
(dropping

the
rope)
was
introduced
as
an
alternative
to
trying
to
this
struggle.
To
begin
the
session,
ask
each
client
to

identify
an
unwanted
experience
by
stating:



“I am a person who dislikes feeling _____________________
(Name
emotion)


After
this
round‐robin
exercise,
state
the
following
suggested
script:



“There’s an aspect of/a part of you, a ‘constant you,’ that notices/observes this feeling or experience when it 
happens; and there’s another aspect/part of you, a ‘content you,’ that tells you things about this feeling, i.e. I don’t 
like it, I don’t want it, things to do to try & get rid of it. This ‘content you’ also has a number of other likes, dislikes 
and roles in life. [Using
yourself
as
an
example,
you
might
say] “For example, I don’t like lima beans, I like carrots; 
I’m a psychotherapist; I’m a woman/man. There are many things my mind knows about me, things I’ve learned 
over time. This is my content me. ”  

A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 49


“Over the past several sessions, we’ve talked about getting to know your co‐pilot, what the co‐pilot says to you, 
what your passengers on the airplane say to you. As you’ve traveled along in life, you’ve had many experiences. 
You’re mind has learned a lot and has many thoughts, opinions, and stories about life—and about you. You carry 
these in your bag, and your cp talks to you about them (what you like & dislike, what you are and aren’t) and 
catalogues all this content about you. This is your “content you.” 

 “Today, we’re going to do a couple of exercises to notice some of this content about you and about each other 
that your copilot’s have put together.”  

Exercise
1:
Noticing
&
Sharing
who
I
am




Consider:
(Use
the
retreat
exercise
(Lori)
of
holding
cards
in
the
4
corners
of
the
room
about
specific
tangible

preferences
in
life
i.e.
Food—hotdogs/burgers,
vegetarian,
ethnic—Chinese/Mexican,
fancy—quail
and
caviar;

Shoes—flip‐flops,
wing
tips,
tennis,
work
boots;
I’m
a:

Cowboy/girl,
cityslicker,
business
professional,
street

hustler;

I
used
to
be
a:

student;
infantryman,
mechanic,
jock
barber;
etc.

I
Hold
these
up
in
“sets”
each
corner

of
the
room
and
have
the
guys
move
to
the
corner
that
best
fits
what
they
like/who
they
are.



have
them
write

their
choices/preferences
on
a
a
card
or
another
option
that’s
not
listed.


Rationale:  The
purpose
of
this
exercise
is
to
explore
the
conceptualized
sense
of
self,
self
as
content
or
“content 
you.”



Materials Needed 

Step 1:  Provide
each
client
with
three
by
five
cards
prepared
before
group.
Then
say
something
like:

Take a 
moment to listen to your Co‐pilot (what your mind is telling you) in order to complete the statements on the cards:


Give
clients
substantial
time
to
fill
in
these
blanks.
This
is
the
primary
exercise
for
this
group.
So,
it’s
important

that
each
client
make
a
concerted
effort
to
participate
and
fill
in
as
many
blanks
as
they
can,
particularly
for
the
“I

am
a”
and
“I
am
not
a”,
sentence
completions.



Step
2:

Pair
clients
up
and
ask
them
to
take
about
5
minutes
to
share
the
information
on
their
cards
with
each

other.


Step
3:

Ask
the
clients
to
return
to
the
group
and
choose
several
clients
to
read
one
or
two
of
their
"I
am
a…"

responses
aloud.
As
they
do
this,
ask
the
following
questions
to
identify
the
“content
you”
vs.
the
“constant
you.”

Point
out
that
the
“content”
in
their
live
change
(the
content
you),
and
there
is
a
“constant”
aspect/part
of
you

(constant
you)
that
notices
this.



1)
Have
you
always
been
a
_________


2)
Do/did
you
enjoy
being
a
__________
(i.e.
do
you
enjoy
it/not
enjoy
it)?



3)
Can
you
be___________
and
another
role
at
the
same
time?



Closure of Session:  

Close
the
session
with
a
general
discussion
of
the
exercise,
using
the
following
suggested
discussion
points,
again

pointing
out
that
the
“content”
in
their
lives
change
(the
content
you),
and
there
is
a
“constant”
aspect/part
of

you
(constant
you)
that
notices
this.


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 50


1.
Discuss
the
process
of
filling
in
the
blanks
by
asking
clients
if
they
noticed
the
task
was
difficult,
easy,
or
had

other
reactions.



2.
Ask
clients
to
look
at
the
like
and
dislike.
How
long
have
they
known
those
things
to
be
true?
Did
you
ever

dislike
something,
and
later
find
that
you
like
it?



3)
Ask
clients
look
at
the
“I
am
a”
statement.
In
group
today,
are
you
still
a_____________________


4.
Ask
clients
look
at
the
“I
am
not
a”
statement.
How
certain
are
they
of
this?
Did
they
used
to
be
this
thing
they

are
not?



Step
4:

Ask
them
to
put
cards
in
their
bags,
stand
and
hold
them
in
front
of
themselves,
and
notice
them.
Ask

them
to
think
of
the
content
in
their
bags—statements
your
copilot
makes
of
what
you
like,
what
you
are
or
are

not,
what
you
want
to
be.
Feel
the
weight.
Can
you
hold
your
bag
lightly—not
take
the
copilot's
statements
so

seriously?


Ask
them,
“Are
you're
co‐pilot's
statements
about
who
you
are
useful?
How
are
they
useful?”



Ask
them,
“How
are
these
statements
not
so
useful?”



Encourage
them
to
think
about
this
and
notice
the
usefulness
of
what
their
content
you/co‐pilot
says
about
who

they
are.















A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 51




Session
11:
Who
is
the
“You”
who
notices?


Purpose: 

The
main
purpose
of
this
session
is
to
connect
with
the
“self
as
constant”
(constant
you).
This
is
the
unchanging

self
who
both
experiences
and
then
notices
the
feelings
and
thoughts
we
have.
The
basic
concept
to
convey
is:


You
experience,
and
you
notice;
and
the
“you”
doing
these
things
has
been
the
same
“you”
your
entire
life.


Prepare:
On
3x5
cards
write
the
name
of
famous/commonly
known
politicians,
athletes,
actors,
cartoon

characters,
musicians,
etc.
with
whom
the
clients
and
staff
are
familiar
(i.e.

General
Patton,
Hillary
Clinton,
Mick

Jagger,
Will
Smith,
Jim
Carry,
Tom
Cruise,
Arnold
Schwarzenegger,
John
Wayne,
President
Obama,
Mickey
Mouse,

Elvis
Presley,
Eric
Clapton,
Charley
Sheen,
Eddie
Murphy,
Magic
Johnson,
Joe
Montana,
Barry
Bonds,
Lance

Armstrong,
Colin
Powell,
clown‐Ronald
McDonald,
astronaut‐Neil
Armstrong,
rap
star,

disc
jockey,
Bill
Cosby,

David
Letterman,
Lucille
Ball,
etc.)
Prepare
as
many
cards
are
there
are
clients.


Prior
to
group
write
on
the
white
board
some
questions
such
as:



1)
What
do
you
do
during
the
day?


2)
What
is
your
favorite
food,
activity


3)
What
do
you
dislike?


4)
Who
do
you
hang
out
with?


5)
What
is
your
next
big
activity/event?


These
are
the
questions
the
clients
will
answer
“as
that
character”
in
the
group.
Don’t
show
them
to
the
clients

until
you
are
ready
to
do
the
role‐playing.




Orientation
to
Group:

Ring
the
Bell


Review & Introduction to Session:  

Remind
clients
that
in
the
last
session
they
became
more
aware
of
their
“content
you”
by
sharing
some
things,

(some
content)
they
know
about
themselves
by
completing
statements
about
what
they
like,
who
they
are,
etc.

Some
of
the
things
might
have
been
hard
to
list.
Begin
this
session
by
noting
that
we’ll
be
focusing
on
another

aspect
of
ourselves,
the
“constant
you.”




Ask
the
clients
if
they’ve
ever
had
the
experience
of
someone
getting
their
name
wrong—called
them
by
a

different
name,
or
mistaken
them
for
someone
else.
Then
note:


 “Our name is really easy to know, and we’ve known it nearly all our life. Because we know it so well, we also know 
well what our name “isn’t”.  

Sometimes it’s easier to know who we aren’t than to know who we are.” 

Exercise
1:

Acting
101


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 52


Rationale: By
acting
as
someone
they
are
not,
clients
will
become
more
connected
to
their
“constant
self/you.”

More
awareness
of,
and
distance
from
(defusion)
the
“content
self”
occurs
when
faced
with
information
(acting

role)
that
does
not
match
that
content.
This
creates
some
space
for
clients
to
notice
their
“constant
self/you”
who

is
doing
the
acting.




Step
1:

Hand
out
the
cards
or
ask
clients
to
draw
one.



Step
2:
Go
around
in
the
circle
and
ask
each
client
to
act
as
their
character,
answering
the
questions
on
the
card.

Consider
starting
with
one
client,
then
asking
them
to
choose
&
solicit
responses
from
another
client.





Step
3:
When
clients
struggle
with
this
exercise
(which
is
expected),
ask
them
what
they
are
thinking
and
feeling

as
they
try
to
act.
They
may
answer
with
“I
don’t
know”,
or
“I
feel
stupid
or
silly”,
“I
can’t
do
this”.



When
clients
describe
these
thoughts
and
feelings,
ask
the
following
questions:



“Who is it that is noticing you are having all these thoughts and feelings?”



“Is it your co‐pilot that’s noticing these thoughts and feelings?  

“It is the passengers on the plane noticing these thoughts and feelings?” 

Step
4:
When
(if)
the
client
states:



“I am noticing that I’m having the thoughts and feelings”,
concur
with
this
by
saying
something
like:


“Yes, you are noticing your thoughts and feelings. We’ve been practicing noticing thoughts and emotions for a 
little while now. You are the one who notices what your co‐pilot says, notices the voices you may have, notices the 
comments of the passengers on your plane, notices whether you’re body is tired or hungry, notices if you’re feeling 
sad or angry. This is the “constant you,” you as the observing pilot that notices all the statements from your co‐
pilot/voices/passengers and physical sensations like being tired or hungry.  

Today, I’m asking you each to act as someone you aren’t. I think we can all agree that we aren’t the character we 
selected. The “you” who notices you aren’t your character, is the same “you” who notices your real name from 
other names, and a lot else about who you are (and who you aren’t)! This is your “constant you” who is attempting 
to act as if you are the character you selected, and who notices that it’s different or difficult.  

Step
5:

After
providing
this
explanation,
suggest
that
the
next
person
go
ahead
and
act
as
if
they
are
their

character.
Then,
inquire
what
thoughts
or
feelings
they
had
when
they
were
acting.
Continue
to
make
this

distinction
(i.e.
that
there
is
a
“constant
you”
who
is
acting
and
noticing
the
thoughts
and
emotions
you’re
having

about
the
acting).



Alternative
Suggestion
to
Acting
Like
a
Character:



If
time
allows,
you
may
also
want
to
ask
clients
if
anyone
has
ever
asked
them
to
be
or
act
like

something/someone
they
aren’t.
Inquire
what
that
was
like?
How
did
the
client
know
she/he
wasn’t
being

himself/herself?
Who
knew
that?
This
is
another
alternative
to
helping
a
client
connect
with
their
constant,

observing
self.



Closure of Group 

A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 53


Remind
clients
that
there
is
a
“constant
you”
who
notices
their
thoughts,
voices,
feelings
&
physical
sensations

and
various
facts
about
themselves.
Remark
that
this
is
the
same
“you”
who
acted
in
character
today
and
who

noticed
if
the
character
you
played
matched
the
facts
you
know
about
yourself,
and
who
noticed
your
reactions
to

that
exercise.
This
is
the
same
“you”
who
notices
when
you
get
into
a
tug
of
war,
trying
to
get
rid
of
thoughts
&

feelings.
Discuss
the
concept
of
your
observing
“constant
you”
knowing
who
you
are
and
who
you
aren’t;
noticing

if
you
are
at
accepting
or
struggling.
This
can
be
as
simple
as
knowing
“what
my
name
isn’t”,
or
can
be
as
complex

as
“there
is
a
‘constant
me’
who
noticed
my
feelings
during
the
exercise
today.”



Respond
to
clients’
confusion
by
noticing
and
describing
it
and
using
this
as
further
experiential
material
for
self
as

context.
For
example,
you
might
say,
“This can be a confusing concept. I’m sense some of you may be at that point 
of confusion right now. Can you use this opportunity (noticing confusion) to become aware that there is a ‘you’ 
who is noticing that you’re confused?”


Homework:



Ask
clients
to
bring
in
a
picture
or
two
of
themselves
when
they
were
younger—as
child,
adolescent,
or
young

adult.
If
the
client
does
not
have
pictures
at
these
ages,
ask
them
to
bring
in
the
youngest
picture
they
have
of

themselves.



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 54


Session
12:
The
“Constant
You”

Purpose: 

The
purpose
of
this
session
is
to
recognize
the
impermanence
of
thoughts
and
feelings
by
further
experiencing
the

“constant
you.”
From
this
perspective
clients
may
realize
they
have
survived
over
time
a
wide
range
of
emotional

and
cognitive
experiences,
and
be
more
willing
to
accept
difficult
current
and
future
experiences.



Prepare:
Client
bring
childhood
picture,
(or
computer
age
regressed
current
photo,
generic
childhood
photo),

client’s
bags


Orientation
to
Group:

Ring
The
Bell


Ask
if
clients
noticed
themselves
“acting”
any
particular
role
this
past
week?

Role
of
patient,
friend,
shopper?

Ask
if
they
noticed
anything
their
cp
said
about
these
roles
or
about
who
they
are,
aren’t
or
should
be?

Ask
if
they
noticed
any
tug
of
war
struggles
over
not
wanting
to
have
certain
thoughts/voices
or
feelings?


Introduction
to
the
Session:


State something like: For the past few sessions we’ve asked you to notice the thoughts, voices & opinions your cp 
gives you about life and about who you are or aren’t. This is a large part of the “content you” your cp, voices & 
passengers have constructed. We’ve also talked about the struggle you carry with you over unwanted 
thoughts/voices and the emotions that go along with them, and to really notice and & get in touch with this 
experience. In a similar way, we also carry other things with us, like the person we were at every age of our life.  

Exercise
1:
Wisdom
with
Age—Images
of
Youth


Rationale:  The
purpose
of
this
exercise
is
first
to
focus
on
recalling
some
content
about
a
childhood
picture
or
a

mental
image
of
the
client
as
a
child.
By
recalling
content,
the
“constant
you”
is
reflecting
on
content
(i.e.
“I
am”
“I

was”).
Second,
by
reflecting
on
a
piece
of
knowledge
that
they
would
share
with
their
childhood
self,
clients

connect
with
their
“constant
you”
through
reflecting
on
lived
experience.


Step
1:

Create
a
childhood/adolescent
mental
picture
of
yourself.
Suggested
script:
“We would like you to do an 
exercise that might be a bit difficult. We want you to create a picture in your mind of yourself when you were a 
child. For those of you who brought in a childhood photo, you can use it; please take it out and look at it. If you did 
not bring one in, please take a few moments and try to create a mental image/picture of yourself as a child. You 
could base it on a picture you might remember seeing of yourself as child or adolescent.”



It's
important
to
help
them
try
to
create
a
strong,
concrete
image.

You
might
ask
them
to
close
their
eyes
and

focus
on
concrete
aspects
of
their
mental
picture—their
hair
(color,
length,
style/cut);
their
eyes
(color,

glasses/contacts,
make‐up);
mouth
(closed/open,
smile/frown,
teeth);
posture
(sitting,
standing,
leaning);
skin

(smooth,
rough,
wrinkled,
make‐up,
facial
hair);
size
(height,
weight,
build);
clothes/accessories
(shirt
style
&

color,
pants,
dress,
shoes,
rings,
watch,
jewelry).
You
could
ask
about
the
setting,
inside,
outside,
sitting,
or
active.






A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 55


Step
2:

Ask
clients
if
they
were
able
to
create
this
mental
picture
of
themselves.
Then
discuss
the
following:


"Who
was
imagining
the
younger
version
of
you?"
or
"who
was
trying
to
do
this,
and
noticing
that
it
was
difficult‐‐
that
it
was
a
hard
to
create
a
picture?”



And
someone
will
say
"I
am".
And
then
you
can
say
"Who is?" ...."You are? And who is the 'you' who is imagining, 
reflecting, recalling this younger version of you?...Who is going back in time to observe this younger you and 
noticing if this is easy, scary or hard? Who is maybe noticing right now that you don’t want to do this?”



Step
3:

Ask,
“Please take another brief moment and notice again your mental picture of yourself as a child, or 
whatever might be close to it.”
Then
ask, “Do you look the same now? Can you see yourself in that younger 
person? Or does it seem that the person in your mental image is totally different than who you are now?” Have 
you changed over time?” 

Elicit
a
few
responses


Then
say
something
like,
“It may seem that we change and become a totally different person from childhood to 
adulthood. Although it’s true that our physical bodies, thoughts, feelings and struggles may change; there is 
something about us that seems to be consistent & stay the same. This is the ‘you’ that notices these changes in 
your body, thoughts & feelings. The you that noticed it was hard, easy or scary to create a mental picture of 
yourself. The ‘ you’ that peered through your eyes as child, adolescent, and adult, to observe/notice. This is the 
“CONSTANT YOU,” you as an observing pilot, that experiences life and notices all the changes in your body, 
thoughts, feelings, & attitudes throughout your whole life.”



Step
4:
Have
them
close
their
eyes
and
then
ask
them
(slow
this
exercise
down):


"Can you see yourself as you are now? Can you see yourself as you were 10 years ago? How about 20,… 30? And 
how is it that you are seeing with your eyes closed? Notice now, that there is a "you" who is reflecting on your 
life...even with your eyes closed. There is a ‘you’ inside who has been there always—a constant you." 




Have
the
clients
open
their
eyes
and
ask,
“If we could make it possible, what is one thing you know now, that you 
would like to share with/tell yourself when you were a child or adolescent?  “If I only knew then what I know now.”


Exercise
2:
I
have
Survived


Rationale:

To
recognize
a
“constant,
observing
you”
that
notices
thoughts
&
feelings
change,
and
realize
that
this

awareness
increases
one’s
capacity
to
carry
them
lightly.


Step
1:
Begin
the
exercise
with
the
following
suggested
script:



“You had many experiences between the time the childhood photo was taken or the childhood mental picture you 
imagined. Sometimes people feel like life experiences change them permanently, so that they are no longer the 
same person they were before the experience. Does anyone feel like that?”  

Discuss
this
question
with
clients.
There
is
a
lot
to
target
in
this
discussion
including:
cognitive
fusion
to
thoughts

about
how
one
has
been
changed
by
their
experiences,
feelings
that
emerged
resulting
from
the
experience
such

that
one’s
day‐to‐day
life
feels
differently,
and
even
somatic
changes
related
to
trauma
(i.e.
chronic
pain,

headaches,
etc).
In
this
discussion,
it
will
be
key
to
address
thoughts,
feelings,
and
all
experiential
changes
in
life

A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 56


as
ones
which
the
client
has
noticed,
i.e.
in
order
to
be
aware
that
their
life
has
changed
from
a
particular

experience
(i.e.
“I
used
to
not
be
so
depressed/anxious,
etc,
but
now
I
am)
there
must
be
a
“you”
who
is
noticing

it,
who
is
able
to
reflect
upon
the
“Then”
and
the
“Now”,
and
the
difference
between
the
two.



Step
2:

Instruct
clients
to
think
of
their
childhood
image
again
and
to
recall
a
difficult
experience
that
occurred

around
that
timeframe.



Following
this
exercise,
ask
the
following
questions
for
discussion:



1)
What
emotions
did
you
feel
as
you
remembered
the
difficult
experience?


2)
Are
these
similar
emotions
you
felt
at
the
time
this
experience
occurred?


3)
Were
you
having
those
emotions
before
you
thought
of
your
difficult
experience?

4)
Can
you
notice
that
you
were
not
feeling
those
emotions
until
you
recalled
this
experience?

5)
Can
you
notice
that
there
is
a
person
(you)
who
is
remembering
this
difficult
event
now,
and
who
experienced

the
event
then?

State
that
this
is
also
your
“constant
you,”
your
observing
pilot.


Step
3:


Hand
out
generic
pictures
of
a
child
to
those
who
don’t
have
one
of
themselves.
Note
that
this
picture

represents
a
picture
of
you
as
a
child.
Instruct
clients
to
put
their
picture
into
their
bag.
Ask
them
to
pick
up
their

bag
and
to
stand
and
hold
it.
State
the
following
suggested
script:



“Today you are holding a bag that contains photos of you at one or two different ages. Today, you are the holder 
of the experiences you have survived, including all the thoughts and feelings that goes along with them. How you 
carry these thoughts and feelings about these experiences can at times feel heavy, interfering, & burdensome. 
We’ve talked about how all humans try different things to “get away” from those thoughts and feelings that are 
difficult or unwanted.”  

Try
now
to
walk
across
the
room
with
your
bag
held
as
far
away
from
you
as
possible.
You’ve
got
all
these

thoughts,
feelings,
and
memories
of
difficult
experiences
of
yourself
at
different
ages
in
this
bag.
Try
really
hard
to

hold
the
bag
as
far
away
from
you
as
possible
while
you
walk.


Step
4:

As
clients
walk
around
the
room
ask
what
it
feels
like
to
try
to
walk
with
the
bag
held
far
away
from
them.

What
would
it
be
like
to
walk
like
this
all
day?
Would
it
be
hard
to
do
other
things
with
an
outstretched
arm
all

day?
Would
it
be
tiring?
Is
this
another
way
to
struggle
with
them,
another
type
of
tug
of
war?



Step
5:


Ask
clients
now
to
consider
a
different
way
to
hold
all
of
these
experiences?
Are
there
more
convenient

ways
to
hold
this
material?
Could
they
roll
the
bag
up
and
hold
it
close
Ask
them
to
try
this.
What
is
it
like
to
carry

their
experiences
this
way?


Group
Closure

Remind
clients
that,
“You
have
a
choice
as
to
how
you
hold
your
memories,
thoughts
and
feelings
you
experience.

You,
your
“constant
you”
is
the
one
who
notices
these
experiences,
and
can
therefore
choose
to
hold
what
he

notices
in
an
awkward,
tiring,
consuming
way.

Or
he
can
choose
to
hold
them
in
a
way
that
leaves
room
for
doing

other
things
in
life.
It
may
be
easier
to
hold
them
close
knowing
from
your
“constant
you”
that
your
thoughts
and

feelings
(even
upsetting
ones)
come
and
go;
change
from
moment
to
moment.




The
next
three
sessions
will
focus
on
values.

Therefore,
provide
a
brief
introduction
to
lead
into
this
for
the
next

session.
Inform
clients
that
there
is
a
larger
reason
why
we
would
ask
them
to
try
“holding
the
bag

close/lightly…dropping
the
rope.”
The
larger
reason
is
that
this
creates
some
room
to
also
notice
what
is


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 57


meaningful
in
life.
Just
like
your
“constant
you”
notices
all
the
difficult
experiences
in
life,
he
also
notices
what’s

enjoyable
and
meaningful.
Noticing
and
doing
some
of
these
things
might
be
rewarding.


Clarification
of
Personal
Values




Goals,
Purpose
and
Process
Suggestions
for
Sessions
13‐15

The
following
three
group
sessions
are
intended
to
target
the
clarification
of
personal
values.
The
overarching

goals
of
values
clarification
are:


1.
Identify
meaningful
valued
domains
of
life.




2.
Define
specific
behavioral
goals
that
align
with
those
values




3.

Identify
potential
barriers
to
following
through
with
valued‐based
living


The
Purpose
of
Clarification
of
Personal
Values


The
overarching
purpose
of
values
clarification
in
ACT
is
to
define
meaningful
areas
of
life
so
that
value
driven

goals
can
be
indentified
and
pursued.
This
process
creates
a
vital
life.
A
more
technical
way
to
understand
this
is

that
values
clarification
enhances
the
potential
for
behavioral/psychological
flexibility.
A
secondary,
yet
equally

important
purpose
of
values
clarification
is
to
provide
rationale
for
why
one
would
intentionally
drop
avoidance

strategies
and
walk
with
or
into
emotional
pain.
Clarification
of
person
values
may
be
considered
the
“why”
of

ACT:
connecting
with
a
vital,
meaningful
existence
is
why
we
are
asking
clients
to
drop
control
strategies
and

move
into
emotional
pain.



The
notion
of
asking
clients
to
move
towards
emotional
pain,
or
to
carry
it
with
them,
may
seem
counter
to
other

therapeutic
approaches
focused
on
reduction
of
symptoms.
The
degree
to
which
a
client
is
in
emotional
distress

may
pull
for
the
clinician
towards
a
goal
of
symptom
reduction:
it’s
what
the
client
may
be
saying
they
want
(i.e.
“I

just
wish
the
voices
would
stop),
may
be
what
the
family
would
also
like
to
have
happen,
and
ultimately
as
a

helper,
symptom
reduction
may
be
the
wish
of
the
clinician.
ACT,
however,
focuses
on
building
and
broadening

emotional
experiencing,
which
includes
the
full
range
of
emotions
(ones
experienced
as
negative
and
ones

experienced
as
positive).



When
addressing
treatment
of
patients
with
a
psychotic
disorder,
no
psychiatric
or
therapeutic
treatment
entirely

removes
the
psychotic
symptoms.
Therefore,
patients
in
this
diagnostic
class
are
left
with
the
usual
range
of

human
pain,
plus
unwanted
symptoms
such
as
hallucinations,
delusions
and
negative
symptoms.
Add
unpleasant

side
effects
from
psychotropic
medications,
and
a
lot
of
unwanted
experiences
may
exist
in
the
life
of
a
patient

with
a
psychotic
disorder.
It
may
be
the
case
that
clinicians
encounter
their
own
strong
wish
to
try
yet
another

strategy
to
remove
these
unpleasant
experiences
for
patients
with
psychotic
disorders
(i.e.
perhaps
a
new

medication
regimen,
perhaps
a
new
coping
strategy).
Alternately,
if
patients
are
exhibiting
more
negative

symptoms
and
less
apparent
distress,
an
approach
of
maintenance
has
been
used
in
rehabilitation
of
those
with

psychotic
disorders.
That
is,
if
the
client
is
not
exhibiting
apparent
distress,
and
is
not
acting‐out
(i.e.
behaving

badly),
and
a
routine
for
life
is
in
order,
then
all
is
well.



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 58


Clarification
of
values
demands
more
of
clients
and
clinicians
than
either
symptom
reduction
or
maintenance.
This

component
of
ACT
addresses
the
meaning
that
inevitably
exists
on
the
flip
side
of
pain.
Theoretically,
where
there

is
loss,
grief,
anger
or
sadness,
there
also
exists
something
meaningful
that
was
lost.
Willingness
to
accept
existing

pain
while
pursuing
meaning,
versus
expending
energy
to
avoid
pain,
broadens
one’s
life
experience.



There
is
a
big
difference
between
values
and
goals,
and
this
will
need
to
be
made
clear
to
clients
at
the
outset.

Values,
as
they
are
discussed
in
ACT,
may
be
conceptualized
as
a
direction
in
which
to
move.
Values
have
no

beginning
or
end
point.
They
are
a
domain
in
which
to
put
energy
and
time.
Goals
are
specific
behaviors
which

have
a
clear
beginning
and
end.
Part
of
clarification
of
personal
values
is
to
define
specific
goals
which
align
with

values.



Barriers
to
completing
those
goals
will
arise
in
the
following
forms:
thoughts,
feelings,
voices,
avoidance

behaviors,
external
barriers
(i.e.
money,
time,
other
people).
Session
15
focuses
on
addressing
these
barriers.
The

main
point
in
addressing
barriers
to
valued
living
is
to
convey
that
there
are
only
perceived
barriers,
not
actual

barriers
to
moving
in
any
valued
direction.
Internal
experiences
like
thoughts,
feelings
and
voices
should
be

addressed
with
acceptance
by
encouraging
clients
to
move
in
their
valued
direction,
completing
their
goals
with

these
experiences.
There
may,
however,
be
an
external
barrier
(i.e.
money)
to
completing
a
specific
goal.
The
goal

can
always
be
changed
to
fit
the
individual’s
current
life
circumstances,
yet
stay
within
the
valued
domain.






Addressing
other
Core
Processes
in
the
Clarification
of
Personal
Values


All
core
processes
are
relevant
to
clarifying
values
and
defining
goals.
Contact
with
the
present
moment
is

required
in
order
to
contact
through
experience
what
is
meaningful.
Acceptance
versus
avoidance
of
a
full
range

of
emotions
is
necessary
when
engaging
in
new
valued
behaviors.
Defusion
from
thoughts
about
embarking
on

valued‐based
behaviors
is
just
as
important
as
is
defusion
from
thoughts
about
avoidance
behaviors.
The
mind

will
tell
stories
about
trying
new
behaviors
just
as
easily
as
the
mind
tells
stories
about
why
one
would
need
to

rely
on
old
behaviors.
Defusing
from
these
thoughts
is
the
key
to
reconnecting
with
the
experience
of
the
new

behavior.
In
the
process
of
clarifying
values
individuals
will
need
to
connect
with
the
consistent
“I”,
or
the

contextualized
sense
of
self,
in
order
to
recall
what
may
have
been
meaningful
in
their
history.
In
order
to
identify

that
a
feeling
or
an
experience
is
painful,
individuals
theoretically
are
comparing
the
experience
of
pain
to
some

other
non‐painful
experience.
Identifying
this
contrast
is
to
identify
what
is
pleasurable
or
meaningful.
This

process
requires
connecting
with
the
range
of
experiences
noticed
by
the
contextualized
self.



Suggestions
for
Group
Process


When
working
on
clarification
of
personal
values
with
clients
who
have
a
serious
mental
illness,
identification
of

meaning
and
behavioral
activation
may
be
inhibited.
This
inhibition
may
be
due
to
a
variety
of
causes,
including

sedating
side
effects
from
psychotropic
medications,
a
long
history
of
being
either
literally
or
figuratively

institutionalized
(i.e.
living
a
very
routine
life,
being
told
what
to
do
by
a
family
member
or
a
conservator),
and

resultant
from
being
inhibited
from
self‐expression
via
the
nature
of
some
mental
health
systems.
Current

recovery
models
of
mental
health
offer
a
more
patient
centered
approach,
developing
and
encouraging

autonomy.
However,
to
the
degree
that
a
patient
has
been
entrenched
in
a
more
hierarchical
model,
where

he/she
may
have
been
given
limits
on
personal
growth,
he/she
may
be
continuing
to
live
within
that
context.



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 59


Addressing
behavioral
inhibition
due
to
medication
side
effects
can
be
done
in
the
group
and/or
with
some

collaboration
with
the
patient’s
psychiatrist
and
the
treatment
team.
In
group,
if
it
appears
a
patient
is
not
in

contact
with
the
present
moment
or
is
sleeping
and
apparently
sedated,
the
orienting
therapist
should
wake
them

up,
and
perhaps
ask
them
to
stand
or
take
a
drink
of
water
to
become
more
alert.
If
homework
is
not
being

completed
because
of
sedation
and
sleeping
in
off‐program
hours,
this
is
an
issue
to
address
in
group
by
first

identifying
the
barrier
(i.e.
sleeping,
medication
sedation),
and
then
stating
the
barrier
to
the
client
(i.e.
“so,
it

feels
to
you
like
the
sedation
from
your
medication
is
interfering
with
your
ability
to
do
your
homework..”).
Then,

some
problem
solving
can
be
done.
You
may
ask:
Could
the
patient
have
taken
the
medication
at
a
different
time

of
day,
so
to
be
less
sedated
and
have
increased
ability
to
complete
the
homework?
Could
the
patient
take
a
nap,

set
an
alarm
clock,
and
have
a
specific
time
to
commit
to
complete
the
homework?



Efforts
at
problem
solving
in
group
will
show
the
client
that
you
are
committed
to
them
following
through
with

valued
living.
If
the
problem
of
sedation
remains
a
consistent
interfering
factor,
then
it
may
be
necessary
to
bring

this
up
with
the
treatment
team
and
the
patient’s
psychiatrist.
Changing
or
reducing
medication
has
its
obvious

downside,
in
that
it
may
increase
symptoms.
From
an
ACT
model,
this
wouldn’t
be
necessarily
a
“bad”
thing,
so

long
as
the
patient
was
willing
to
tolerate
increased
symptoms
in
the
service
of
less
sedation
and
increased
ability

to
engage
in
daily
valued
behaviors.
These
types
of
decisions
should
be
carefully
weighed
with
the
treatment

team
with
the
psychiatrist’s
direction.


If
a
patient’s
inhibition
appears
to
be
from
a
history
of
institutionalization,
the
ACT
model
is
going
to
feel
like
an

entirely
new
approach.
The
active
participation
asked
of
patients
in
the
preceding
groups
may
have
felt
confusing,

even
frightening
to
clients
who
have
spent
much
of
their
adult
life
institutionalized.
If
a
patient
has
been

institutionalized
or
lived
in
a
structured
environment
most
of
their
adult
life,
there
may
be
a
lot
of
compliance
to

the
therapist’s
requests.
This
can
appear
like
engagement
in
group
activities.
However,
values
clarification
asks

clients
to
generate
goals
with
personal
meaning,
which
requires
more
personal
assertion
than
anything
previous

in
this
protocol.
Generation
of
independent
ideas
of
what
one
enjoys
in
life
may
be
quite
difficult
for
one
who
has

been
told
what
to
do
most
of
their
adult
life.
The
best
way
to
address
this
with
the
patient
is
to
do
so
directly.
You

may
ask,
“when was the last time anyone asked you what you wanted in your life?”

Or,
“what does it feel like for 
me to ask you what you’d like to do in your life?”
If
there
is
a
predominance
of
clients
who
have
lengthy

institutionalization
histories,
it
may
be
useful
to
take
some
time
to
directly
discuss
how
the
group
therapy
you’re

providing
is
likely
different
from
any
to
which
they’ve
previously
been
exposed.




It’s
a
good
idea
to
directly
state
what
you’d
like
for
the
patients
in
the
process
of
values
clarification
(i.e.
“I’d really 
like to see each of you live a life that makes you excited to get up in the morning. I believe that’s possible for you!”

Expressing
your
own
excitement
and
motivation
can
serve
as
a
model
that
you
won’t
be
punishing
or
negative

about
new
ideas
expressed
by
clients.
Another
strategy
for
activating
more
inhibited
clients
is
to
suggest
a
goal
to

them
that
is
more
lofty
than
what
they
might
generate.
By
using
more
extreme
examples,
you’re
providing

permission
for
the
clients
to
develop
a
voice
for
their
own
goals.



As
an
ACT
therapist,
you
may
the
first
person
who
has
encouraged
the
patient
with
a
psychotic
disorder
to

express
personal
ideas
about
what
is
meaningful.
It
may
be
that
the
patient
has
been
told
that
his/her
ideas
are

“crazy”,
“bizarre”
or
otherwise
unworthy.
A
lack
of
forward
movement
in
life
may
be
self‐evidence
that
others
in

the
individuals’
life
are
“right”
about
this.
Therefore,
values
clarification
is
the
first
step
towards
autonomy
for

some
clients
with
psychotic
disorders
through
self
trust,
self
expression,
and
successful
goal
completion.
As
clients

express
confusion,
bewilderment,
anxiety
or
other
emotions
about
your
approach,
it
is
your
job
to
notice
those

reactions
and
stay
consistent
with
your
behavior
towards
the
patients.


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 60


Session
13a:

Values/Goals—What
I've
Been
Told
(optional
session)

Purpose:



The
purpose
of
this
session
is
to
address
a
powerful
initial
barrier
to
values
and
goal
clarification
frequently

encountered
by
clients
with
psychotic
disorders—institutional/social
pliance.
These
clients
have
been
told

frequently
in
word
and
deed
often
by
well‐meaning
people
in
authority
that
they
are
incapable
of
obtaining
or

fulfilling
typical
social
roles,
and
that
they
should
abandon
their
desires
(what
they
value)
and
focus
on
minimal
or

modest
aspirations
scripted
by
those
who
"know."
By
coming
in
contact
with
this
dimension
of
the
content
self
in

this
session,
clients
will
defuse
a
little
from
this
content,
weaken
this
barrier
and
create
a
little
space
to
consider

what
life
pursuits
might
be
meaningful
to
them.


Prepare:

Bring
the
white
board


Orientation
to
Group:

Ring
the
Bell


Briefly
Review/Introduce
Session:



Review
that
the
last
few
sessions
we’ve
become
more
aware
of
our
“constant
self”
the
“constant
you,”
you
as
the

observing
pilot
that
notices
all
your
thoughts,
voices,
feelings
&
physical
sensations.
A
week
before
that,
we

looked
at
our
“content
you”
what
our
copilot
to
say
about
all
the
things
we
notice
and
experience
in
life.
He

makes
comments
about
"what
you
like,
who
you
are,
what
you
want"
and
he
might
make
some
positive

comments
or
some
pretty
negative
ones.
Indicate
that
this
week
we're
going
to
be
looking
at
what
our
co‐pilot

and
passengers
on
our
plane
have
to
say
about
"what
we
can
do."


Exercise
1:

Interviewing
your
passengers


Rationale:


The
purpose
of
this
exercise
is
to
identify
prominent
people/entities
in
the
clients'
lives
that

influence/define
their
aspirations
and
goals,
and
cast
them
as
passengers
they
carry
on
their
plane.
By
placing

them
in
this
position
and
soliciting
their
comments
(via
interview)
regarding
what
they
think
the
client
is

able/capable
of
doing,
some
diffusion
will
occur
and
the
client
will
be
better
able
to
notice
them
as
another

"thought"
that
can
simply
be
observed
or
assessed
for
it's
usefulness.


Introduction:

Say
something
like,
"Throughout
our
life
as
we
get
up
each
day
and
fly
here
and
there,
we
heard
a

lot
from
others
about
what
we
should/shouldn't
do,
can/can't
do,
or
even
what
they
think
we're

capable/incapable
of
doing.

What
are
some
of
the
sources
of
these
messages;
who,
what
groups
or
entities
tell
us

these
things?"



Step
1:

Ask
the
clients
to
identify
these
people,
groups,
or
entities;
and
list
them
on
the
white
board
under
the

heading
"passengers."
If
they
struggle
some
options
are:

parents,
teachers,
society,
media,
voices,
church
leaders,

military
CO's,
friends,
siblings,
doctors,
nurses,
therapists,
politicians,

etc.


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 61


Step
2:

Ask
the
clients
to
think
for
a
moment
about
what
they
have
heard
these
people
or
entities
say
about
what

they
should/shouldn’t,
can/can't
do
or
are
capable/incapable
of
doing.
Solicit
a
few
responses
and
list
them
on

the
white
board
under
the
heading
"message."

**Pull
more
for
negative
messages,
add
AH
&
PI—can't
do,
not

capable
of
doing"


Step
3:

Invite
a
client
who
would
be
willing
to
share
in
more
detail
their
thoughts
to
the
questions
above
to
help

with
an
exercise.
Ask
him
specifically
what
people,
groups,
entities
have
had
a
big
say
on
his
life
goals
and

aspirations—what
he
would
like
to
do
or
become.


Invite
other
clients
to
come
up
and
represent
these
people
or

entities.
As
in
past
groups,
set
up
an
airplane
with
chairs
for
the
pilot,
copilot
and
passengers
&
have
everyone

take
their
designated
seats.



Step
4:

Address
the
pilot
and
say
something
like,
"This
is
a
unique
set
of
passengers
on
your
plane
today.
They

have
something
to
say
about
a
critical
part
of
your
flight.
They
are
trying
to
tell
YOU
'the
pilot'
where
to
fly
the

plane.

I
would
like
you
to
interview
them
one
at
a
time."


Have
the
pilot
put
the
plane
on
'auto‐pilot'
and
instruct
him
to
ask
each
of
the
passengers
one
question:







"What
can
I
do
with
my
life?"
(Possible
2nd
question,
"Tell
me
one
thing
you
think
I
can
or
can't
do.")



Assist
the
pilot
in
interviewing
the
passengers.
The
passengers
may
not
know
how
to
respond
to
the
question
via

the
pilot's
perspective.
Have
the
pilot
supply
this
information
and
have
the
passenger
repeat
it
back.

Notice
the

pilot’s
emotional
reaction,
you
may
want
to
highlight
&
work
with
it.



Step
5:

Have
the
pilot
ask
the
question
of
his
passengers
a
second
time.
As
he
hears
a
response,
stop
the
action

for
a
moment
and
say
something
like,
"Let's
pause
a
second,
and
I'd
like
to
check
in
with
you,
the
pilot.

Right

now,
in
this
moment,
how
much
do
you
believe
what
this
passenger
just
said
to
be
true?"
Suggest
a
0‐10
scale—
where
0
is
"I
don't
believe
it's
true
at
all"
5
is
"it
might
be
true"
and
10
is
"It's
absolutely
true,
I
believe
it
100%.

(The
assumption
around
assessing
believability
is
that
the
thoughts
will
stay
but
the
extent
to
which
one
believes

them
to
be
true
is
the
degree
of
cognitive
fusion
versus
defusion
one
has
with
the
thought.)


Show
some
reaction
to
the
degree
of
believability
and
provide
an
experiential
anchor
for
it
via
responses
such
as:



Low
believability:


"Oh,
so
you
believe
it
about
as
much
as
you're
going
to
win
the
mega‐lottery
today."

"Okay,
so
it
seems
like
you
hold/take
this
statement
lightly‐
kind
of
like
we
held
the
thoughts
lightly
in
the
bag"

"Oh,
so
you're
maybe
noticing
that
this
is
just
your
passenger
talking
'smack',
and
it
really
doesn't
match
your

actual
experiences
in
life."




Medium
believability:


"So
you
believe
this
kind
of
like
you're
cutting
things
close
but
pretty
sure
you'll
make
it
to
the
bus
stop
on
time

(have
enough
gas
in
your
car),
but
you're
not
too
certain.

"Oh,
so
this
statement
has
some
weight
to
it;
it
would
weigh
a
few
pounds
if
you
held
it
as
one
of
your
thoughts
in

the
bag."

"Okay...so
have
you
had
a
few
life
experiences
with
this
being
true
for
you?"



High
believability:


"Wow.
So
this
statement
feels
as
real
to
you
as
this
chair!
OR
as
real
as
you
and
I
standing
here
talking."

"Dang,
this
thought
weights
a
ton;
you
can
barely
carry
your
bag
with
it
in
there.


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 62


"Okay...so
have
you
had
some
life
experiences
with
this
being
true
for
you?"


"So,
this
is
a
really
loud,
powerful
passenger!
Does
she
say
this
ALL
the
time?
Is
it
pretty
hard
to
ignore?"



If
there's
time,
do
this
with
a
few
of
the
statements
the
other
passengers
make.


Try
to
do
this
entire
exercise
with
at
least
2‐3
clients,
time
permitting.



Discussion:


With
all
the
clients
back
in
the
group
consider
asking/discussing:


Do
you
know
what
direction
your
plane
has
been
flying
while
you
were
talking
with
your
passengers?

How
much
are
you
swayed/influenced
by
your
passengers'
statements?


Have
you
always
believed
your
passengers
as
much
or
as
little
as
you
do
now?

With
all
the
talk
is
it
hard
to
even
stay
in
the
present
moment?


How
hard
is
it
to
find
the
direction
you
want
to
fly
with
all
they
say?




Could
someone
with
a
mental
health
condition
become
a
__________
(insert
roles
clients
said
they
couldn’t

be/do)?


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 63


Session
13b:

Where
Do
I
Want
to
Fly?

Purpose:


The
purpose
for
this
session
is
to
define
one
valued
domain
that
holds
meaning
for
each
client.
When
conducting

individual
ACT
therapy,
time
allows
for
several
domains
to
be
identified.
Given
that
group
therapy
allows
for
less

individual
attention
to
each
client,
the
goal
of
this
session
is
to
identify
one
area
of
life
which
truly
holds
meaning

for
each
client.
Homework
for
this
session
will
require
the
client
to
work
with
a
partner
during
the
week.
The

partner
can
be
another
client
from
group.
With
that
person,
the
client
will
work
to
develop
2‐3
specific
goals
that

align
with
the
valued
domain
and
bring
those
to
group
for
session
14.



Prepare:

1
)
Bring
the
White
Board


2)
Posters
printed
with
the
following
valued
life
domains
(Before
beginning
group,
make
they
are
taped
on
the

door/wall):



Mental/Physical
Health

Spirituality

Family
Relationships


Friends/Social
Relationships

Romantic
Relationships

Career/Job
Development

Recreation/Sports

Financial
Stability

School/Creative
projects

Citizenship/Community
Groups


3)
Valued
Domain
Cards
3
x
5
w/valued
domains
printed
on
them


4)
"I
Value
this
Because"
Posters:
"Somebody
else
wants
me
to
or
they'll
like
it
if
I
do."
"I
should
want
it."
"I
would

feel
embarrassed,
ashamed,
guilty
or
anxious
if
I
didn’t."
"I
see
it
as
important
whether
or
not
others
agree."
"It's

less
risky,
scary,
or
will
hurt
less
than
other
options."
"I
notice
it
makes
my
life
better,
more
meaningful,
more

vital."
"I
notice
it's
enjoyable
or
fun
when
I'm
involved
in
it."





5)
Copies
of
the
homework
“Identifying
Specific
Goals”


Orientation
to
Group:

Ring
the
Bell


Review
&
Introduction:


Say
something
like:
" In many ways in this group we've been building up to this point. We've worked on trying to 
be "present" for what's going on in and around us. We've looked at our thoughts & feelings and what we try to do 
A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 64


with them vs. having them. We've looked at what our copilot, passenger, and other voices say to us; and in 
particular what they say about "who we are," and "what we can or can't do." Today we're going to ask you,  the 
observing pilot, your “constant you,” to lightly hold all these things we've discussed up until now, and consider one 
question, "As of right now, where do you want your life to go. Where do you want to fly your plane?"


Exercise
1:
The
Best
Part
of
My
Day


Rationale:

The
purpose
of
this
exercise
is
to
facilitate
a
discussion
of
simple
meaningful
activities,
and
have
them

briefly
experience
the
pleasure/enjoyment
in
them.
This
exercise
is
a
nice
opportunity
for
the
therapist
to
target

clients
who
are
inhibited
or
have
difficulty
expressing
personal
meaning
or
enjoyment.



Step
1:

Ask
clients
the
following
question:




“…As part of this, I want to ask you a simple, yet possibly challenging question ‘When you are awake, what is the 
most enjoyable or meaningful part of your typical day?’ Try to think of something that you do most days. It doesn’t 
need to be a big thing, it could be something small, like something you see on the bus ride here, a cup of coffee, or 
someone you enjoy spending time with.” 

Go
around
the
room
and
elicit
a
response
from
each
person
(time
permitting)—list
them
on
the
white
board.
As

clients
say
what
they
most
enjoy,
ask
the
following
question:



“What makes ________________ the best or most enjoyable part of your day? How do you feel when you are 
doing that thing?”  

As
clients
share
the
best
part
of
their
day,
it
will
be
important
to
focus
on
how
the
client
feels
when
doing
this

behavior.
The
way
in
which
you
relate
to
the
client
as
he/she
explains
this
will
be
important.
Really
“be there”

with
the
client.
For
example
you
could
say,
"Take
me
there,
what's
it
like
when
you…"
"What
part
of
it
grabs
your

attention;
what
emotions
emerge
?"
It’s
important
in
this
exercise
to
bring
the
experience
to
life,
elicit
that
same

emotion
in
the
room
as
they
describe
it,
and
for
clients
to
connect
in
the
room
with
their
experience
of
doing

something
enjoyable/meaningful.



Exercise
2:
Metaphor:
Flying
South



Rationale:

The
purpose
of
this
exercise
is
to
introduce
the
concept
of
valued
directions.
The
metaphor
of
the

copilot/passengers
is
brought
back
to
convey
the
process
of
shifting
directions
in
life
and
that
it
will
require

defusing
from
voices/thoughts
to
find
one's
valued
direction.



Step
1:

Intro—Ask
the
group,
"What
if
you
could
have
that
feeling
you
get
during
the
best
part
of
your

day…MORE
OFTEN?"
Share
with
the
group
that
the
purpose
of
this
therapy
is
to
build
more
"best
parts
to
their

day—more
meaningful,
enjoyable
experiences."


“You may recall that we each have a co‐pilot & passengers feeding us thoughts all day long. Some of these 
thoughts may tell us which direction to fly in our airplane. This may be a direction where we do not want to go. 
Today, already, you have described the best part of your day. Now, we’re going to think a little bigger than just the 
best part of your day. The next part of our work in this group is going to ask you to define where you’d like to fly in 
your plane.”  

A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 65


“For example, let’s say you’ve been flying south for the last 15 years. Your co‐pilot has insisted that every morning 
for the past 15 years, when you take off in your airplane that you fly south. There’s nothing wrong with flying 
South. However, it’s not the direction you want to go.”  

“So, let’s say you want to go to North. You’d have to deviate from the co‐pilot’s instruction! He’s saying really 
loudly “No, NO! Go South!!” And even as you’re flying north he’s screaming at you to turn the plane around. This is 
sometimes what life is like. You may have set out on a journey long ago to have a family or a certain type of job, or 
some other meaningful direction in life. There are several areas of life where we can put our energy (reference the 
valued domains on the whiteboard). So, using this metaphor, people might put all their time and energy into 
building a career they don’t really like because their co‐pilot said they should, or maybe a passenger on the plane, 
like their mom or dad’s voice insisted they should. That’d be like flying South every day. But, instead, what they 
really wanted to do was to have a simple job, like a bell hop, and build a romantic relationship and spend energy 
there. For them, that’d be like flying North.”  

“We’d like to help you find what direction would be most meaningful to you in life. Where would you like to put 
your energy in life as you ‘take off’ each day?”  

Exercise
3:
Choosing
a
Direction



Rationale:

The
remaining
portion
of
the
session
should
be
used
to
help
clients
identify
one
valued
direction
that
is

meaningful
to
them.
In
some
cases
this
can
be
identified
through
the
best
part
of
their
day.
The
purpose
of
this

exercise
is
to
have
clients
pick
either
one
or
two
valued
directions
in
which
they’d
like
to
move
in
life.
It
matters

little
whether
they
are
truly
connected
to
the
domain
they
choose,
because
the
work
ahead
(i.e.
creating
goals)

will
clarify
if
this
is
a
truly
meaningful
area
of
life
or
an
arbitrary
choice.
If
the
next
step
of
goal
setting
lacks

meaning,
the
client
can
always
select
a
different
domain
of
life.
The
point
of
this
exercise
is
for
the
client
to
make

a
choice,
be
autonomous
in
that
choice
(i.e.
that
they
are
not
told
what
to
choose)
and
that
they
feel
supported
in

that
choice.



You
may
use
the
following
suggested
script:



“Take a look at these areas of life. Imagine that you could fly in any of these directions in a limitless way. What 
direction would you fly; which area would you pick?  

Notice if your co‐pilot or passengers are saying anything right now. See if you can just notice and let go of what 
they might be saying. They may be telling you a bunch of reasons why you can’t pick a certain direction. However, 
I’d like you to go ahead and pick it anyway. If you aren’t sure between one or two “directions” (valued directions) 
you can go ahead and choose two. It’s best if you could narrow it to two.”  

Ask
if
the
clients
have
noticed
the
other
posters
around
the
room.
Say
that
they
represent
some
of
the
things

“thoughts”
they
might
be
hearing
from
their
co‐pilot,
passengers,
or
voices.
Go
around
and
have
different
clients

read
one
and
ask
if
anyone’s
getting
that
type
of
message
from
their
cp
or
passengers.
Encourage
them
to

“notice”
these
thoughts,
and
to
re‐direct
their
attention
to
the
list
of
life
domains
and
choose
the
one
that
is
most

meaningful
to
them.


*Place
the
stacks
of
value
domain
cards
out
and
let
clients
know
that
after
they
consider
this
for
a
while,
they
can

walk
up
and
pick
the
domain
card(s)
that
match
what
they’ve
selected.



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 66


Both
therapists
should
walk
around
the
room
working
individually
with
clients
as
they
choose
their
top
valued

domains.
Since
this
exercise
is
about
building
a
voice
for
the
client
and
building
autonomy,
it
is
important
that

whatever
the
client
selects
be
done
in
the
most
independent
manner
and
be
supported
fully
by
the
therapist.
As

the
therapists
discuss
individually
with
clients
this
process,
they
may
continue
use
of
the
co‐pilot
metaphor
to

target
defusion
and
acceptance
in
the
decision
making
process.
For
example,
the
therapist
could
say
“what seems 
to be difficult about making this decision? What’s your copilot telling you?”
or
“Are you afraid of choosing?”
and

“Are you willing to feel that fear and pick one anyway?” It
may
also
be
useful
to
target
the
consistent
“I”
by
asking,

“Do you remember a time when you were on a different course in life? Flying in a different direction that felt more 
vital, more alive, more meaningful?”
Clients
may
believe
they
can’t
ever
return
to
that
course.
While
the
specific

goals
may
no
longer
be
attainable,
the
valued
direction
can
be
re‐accessed.



* 
After
the
members
have
selected
their
cards
and
if
there’s
time,
invite
members
to
share
with
the
group
the

valued
domain(s)
they
selected


Instructions
for
Homework
and
Closure
of
Session



Hand
out
the
worksheet
“Identifying
Specific
Goals”



Provide
clients
instruction
on
how
to
complete
this
with
someone
of
their
choosing
(other
client
in
group,

therapist
or
family
member).
The
instructions
will
need
to
review
the
difference
between
goals
and
values.
You

may
use
the
following
suggested
script
after
providing
the
handouts
to
each
client:



“Today you identified one or two valued directions that would be your top valued domains‐ where you want to put 
your energy in life. This is a direction you can keep moving forever. For example, you could continue to fly South 
and fly South for the rest of your life‐ or you could change direction and fly North for the rest of your life. 

We’re asking that you spend some time this week choosing 2‐3 specific goals within your valued direction. This 
would be like picking a destination. Let’s say your value was to fly North. You could have three destinations: 
Compton, Santa Barbara, Canada. The first would be a short trip (like a short term goal), something you could do 
this afternoon. The third could be a long term goal, even something that might take years to complete.”  

Right
now,
everyone
select
a
partner
in
the
group
with
whom
you
can
work
on
this
assignment.



(Have
clients
select
a
partner)


Close
group
by
thanking
clients
for
their
willingness
to
participate
in
the
group
and
completing
the
assignment.





A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 67


Session
14:
Defining
My
Next
Destination

Purpose: 


The
purpose
for
this
session
is
to
further
clarify
one
or
two
valued
directions
in
which
each
patient
would
like
to

move,
and
to
define
attainable
goals
in
harmony
with
this
value.
Over
the
course
of
the
last
week,
clients’

homework
was
to
define
2‐3
goals
that
align
with
the
valued
domain
of
their
choosing.
It’s
likely
that
several

barriers
arose
in
this
process.
It’s
not
expected
that
clients’
will
have
done
this
task
with
ease,
or
that
they
will

have
completed
it
without
struggle.



This
session
provides
reorientation
to
clarifying
a
valued
domain,
discussing
the
process
of
the
weeks’
homework,

and
creating
2‐3
attainable
goals.
For
all
clients
at
least
one,
if
not
two
of
the
goals
should
be
immediately

attainable,
so
that
immediate
success
can
be
experienced
through
committed
action.
Clients
who
did
complete

the
homework,
will
be
asked
to
assist
their
peers
in
this
process.



Prepare:
Put
up
(or
leave
up)
the
valued
life
domain
posters,
Life
domain
cards?,
Copies
of
the
homework

“Exploring
New
Terrain”



Orientation
to
Group:

Ring
the
Bell


Review/Introduction to Session 

Remind
clients
of
last
week’s
session
&
homework
assignment:
Choose
where
you
want
to
fly…what
you
want

your
life
to
be
about
&
to
work
with
their
peer
partner
to
develop
three
goals
that
align
with
this
direction.

Restate
that
the
focus
of
the
next
several
groups
will
be
to
engage
in
some
new
behaviors
in
life
with
the

intention
of
making
life
more
meaningful.
At
this
juncture,
introduce
the
concept
of
barriers
to
values.
Given
that

some
people
will
not
have
completed
the
first
values
homework
assignment
it
will
be
key
to
introduce
barriers
to

valued
living
at
this
time.
You
may
use
the
following
suggested
script,
focusing
on
the
different
types
of
potential

barriers:



“Have you ever taken a trip where everything went smoothly…, 100% hassle free?  Similarly, as part of your 'valued 
direction' journey, things are bound to come‐up which seem to interfere with the trip—with the process of setting 
new goals and making some changes to your life: 1) You may have confusion about figuring out what is 
meaningful, and feel stuck with how to begin 2) you may experience difficult feelings that seem to keep you 
“stuck” like depression or anxiety—what some people see as symptoms of mental illness 3) you may have thoughts 
or voices about why setting new or meaningful goals won’t work or won’t be possible. We understand that these 
things may seem like brick walls, standing in the way of the work we’re asking you to try. Maybe sometimes you 
just don’t want to do something new. This is understandable and almost to be expected. This journey requires 
some real willingness, and we want to acknowledge we’re asking you for that in these groups.”  

Exercise
1:
Goal
Sharing


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 68


Rationale:

This
exercise
provides
an
opportunity
for
clients
who
completed
the
homework
assignment
to
share

the
value‐based
goals
they
set.
It
is
also
an
opportunity
for
positive
reinforcement
of
homework
completion
(i.e.

the
attention
and
initial
time
in
group
is
given
to
those
who
completed
the
work).



Step
1:

Ask
for
a
show
of
hands
as
to
how
many
people
did
the
assignment
of
creating
the
2‐3
goals
that
align

with
the
valued
direction
they
chose.



Step
2:

Ask
those
who
did
the
assignment
to
share
their
value
and
the
associated
goals.

It’s
very
important
that

the
clients
sense
that
these
assignments
are
really
important.
Liberally
praise
those
who
did
the
assignment
and

not
punish
those
who
didn’t
(typically
clients
hope
the
therapists
forget
that
they
gave
homework
or
to
check
on

it).
For
this
sharing,
ask
each
client
to
address
the
following
questions
as
briefly
as
possible
(you
may
write
these

on
the
white
board).
This
portion
of
the
group
should
be
fairly
quick
to
allow
for
the
working
section
of
this
group.

If
it
seems
that
one
of
these
questions
is
going
to
take
some
time,
move
on
to
the
next
client.
Clients
will
have

time
later
in
the
group
to
work
on
the
answer
to
these
questions.




1)
What
are
the
valued
domain/domains
you
selected?



2)
Who
is
your
peer
partner?



3)
What
are
the
three
goals
you
developed
with
the
help
of
your
partner?



4)
Can
you
commit
to
making
an
attempt
at
following
through
with
at
least
one
of
those
goals
within
the
next

week?



5)
At
this
point,
are
you
satisfied
with
the
valued
domain
you
selected
and
the
goals
you
have
developed
so
far
(or

have
you
realized
you
want
to
change
the
valued
domain
or
goals
you
work
on
in
this
group)?


If the client has been unable to form goals that seem attainable, or has been unable to formulate three goals, then 
this will be an area of work for them in the group today. Selecting a different valued domain at this juncture is not 
ideal, since it may be best if the client first try completing the goals to connect with the value. Reselecting a 
different valued domain may serve as an avoidance strategy to doing the work. However, if a client has found 
creating meaningful goals unworkable during the week, he/she is always free to select a new valued domain.  

Exercise
2:
Helping
Each
Other
Find
New
Beginnings


Rationale:

This
exercise
is
designed
to
target
barriers
to
the
initial
homework
assignment
for
those
who
did
not

complete
it,
and
to
facilitate
identification
of
2‐3
value‐based
goals
with
the
help
of
peers
who
did
complete
it.




Step
1:

Ask
each
client
who
completed
the
homework
(at
least
in
part)
to
select
a
client
who
did
not
complete
the

homework
as
a
group
partner
for
the
day.
Remind
clients
that
they
will
continue
to
work
with
their
original

partner
throughout
the
next
week.



Step
2:

Explain
that
the
next
30
minutes
will
be
spent
working
with
their
partner
on
two
things:



1)
Helping
the
peer
partner
to
complete
the
homework
that
was
not
completed
during
the
week


2)
Asking
for
help
completing
any
portion
of
their
homework
that
remains
to
be
completed
(i.e.
if
they
wanted
to

reselect
a
different
valued
domain,
or
if
they
need
to
create
a
second
or
third
goal,
etc).



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 69


Both therapists will need to be active facilitators of this working session, ensuring that clients are on task, and 
helping each other create 2‐3 valued‐based goals. Attention will need to be given to goal setting being an active 
process on both parts (i.e. the client who completed their homework should not be telling the other client what 
their goals “should” be).  

Closure of Group:  

Reconvene
group,
and
ask
clients
to
sit
next
to
their
original
partner.
With
any
remaining
time,
ask
that
they
share

with
their
peer
partner
any
new
goals
set
today.
Since
clients
switched
partners,
clients
who
did
not
complete
last

week’s
assignment
will
need
to
share
with
their
peer
the
goals
created
in
today’s
session
(or
any
changes
made).



Remind
clients
that
this
week
they
will
work
with
their
original
partner
with
two
tasks:



**If
there
is
time
in
group
for
clients
to
schedule
the
meeting
time
with
their
peer,
this
is
ideal.


1)
Continued
commitment
and
support
on
following
through
with
one
goal.



2)
Schedule
a
time
(at
least
30
minutes)
to
meet
together
to
complete
the
worksheet:
“Exploring
New
Terrain”.



Before
group
ends,
ask
that
each
client
make
a
verbal
commitment
to
their
partner
to
complete
the
goal,
and
to

meet
at
the
set
time.



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 70


Session
15:
Exploring
New
Terrain

Purpose: 

The
purpose
for
this
session
is
to
discuss
clients’
experiences
of
selecting
the
valued
domain,
creating
goals,
and

making
an
attempt
to
follow
through
with
a
goal.
It’s
safe
to
assume
that
this
may
have
been
a
difficult
process
in

many
respects.
First,
as
previously
stated,
making
choices
about
life
direction
may
be
either
a
new
or
unfamiliar

process
to
clients
with
a
long
history
of
severe
mental
illness.
Being
asked
to
formulate
a
meaningful
set
of
goals

and
follow
through
with
at
least
one
of
them
may
have
seemed
like
an
overwhelming
task.



Clients
likely
experienced
a
range
of
emotions
with
the
past
two
weeks
of
group.
Some
people
may
have

connected
with
feelings
of
joy
and
success.
Some
clients
may
have
experienced
confusion,
paranoia,
increases
in

symptoms,
or
perhaps
felt
burdened
by
the
task.
Some
may
have
been
fearful
of
punishment
if
the
task
wasn’t

completed.
This
group
leaves
room
for
expression
of
those
experiences.
Lastly,
in
discussing
the
experience
of

connecting
with
what
is
meaningful
provides
opportunity
to
target
the
other
5
core
processes
in
session.

Metaphors
such
as
the
co‐pilot,
tug
of
war
with
the
monster,
the
“consistent
I”
and
others
that
the
therapist
finds

useful
may
be
used
during
this
process.



Prepare:  

Write
the
questions
from
Worksheet
1,
“Exploring
New
Terrain”
on
the
white
board,
or
poster
paper.



The
first
part
of
the
session
will
be
spent
discussing
clients’
experiences
completing
new
goals
and
meeting
with

their
peer.
Questions
from
Worksheet
1
will
serve
as
a
guide
for
this
discussion.



The
second
part
of
the
session
will
be
used
to
discuss
barriers
that
interfered
with
homework
completion.


Orientation
to
Group:

Ring
the
Bell


Review/Introduction to Session  

Begin
by
reminding
clients
that
in
the
past
two
sessions
you’ve
asked
them
to
do
something
that
may
have
been

very
new:
Identifying
what
is
valuable
and
creating
goals
in
line
with
that.



Exercise
1:
Initial
Discussion
Regarding
Values
Clarification



Facilitate
a
discussion
on
clients’
experiences
related
to
the
past
two
sessions.
Use
the
following
points
as

guidelines
for
the
discussion.



Step
1:

Ask
the
group
some
questions
to
facilitate
the
discussion:



1)
“Has anyone ever asked you to define what is meaningful in your life?”



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 71


 2)
“What has it been like to meet with your peer once a week for the past two weeks?”




3)
“What have been some reactions to the exercises in group and outside of group in the past two weeks?”



4)
“Do you feel that you’ve connected with something meaningful during this work? If so, how do you know? If not, 
how do you know?”  

This
discussion
should
serve
to
set
the
stage
for
a
more
in‐depth
discussion
of
the
feelings
and
thoughts
that

arose
during
goal
setting,
and/or
those
that
arose
for
clients
who
did
not
participate
in
the
work.


Exercise
2:
Chain
Analyses
of
Client
Behavior


Rationale:

You’ll
be
conducting
at
least
two
chain
analysis
related
to
the
process
of
selecting
valued
domains
and

goal
setting.
You
may
conduct
chain
analyses
related
to
either
of
those
activities.
The
chain
analyses
serve
as
data

for
the
therapist
and
the
client,
so
both
may
gain
a
better
understanding
of
the
process
of
choosing
values
and

defining
goals.

Also,
the
process
of
conducting
a
chain
analysis
serves
as
an
opportunity
for
clients’
expression
of

their
experiences
during
homework
and
in‐session
activities.



Instructions  

Step
1:

Ask
for
show
of
hands
for
who
met
with
their
peer
this
week.



Step
2:

Of
those
who
met
with
their
peer,
ask
how
many
people
completed
a
short
term
goal
and
discussed
this

with
their
peer.



Step
3:

You’ll
want
to
congratulate
anyone
who
successfully
completed
the
homework.



Step
4:

Ask
one
client
who
is
willing
to
share,
how
or
why
they
were
willing
to
meet
with
their
peer
and
complete

their
goal.



Step
5:

Using
the
whiteboard
version
of
“Exploring
New
Terrain”,
worksheet
2,
walk
the
client
through
a
chain

analysis
of
goal
completion
(i.e.
what
were
the
feelings
and
thoughts
before,
during
and
after
the
goal

completion).



Step
6:

Now
ask
for
a
show
of
hands
of
who
did
not
complete
the
homework
(i.e.
those
who
either
did
not
meet

with
their
peer,
or
those
who
met
with
their
peer
but
did
not
complete
a
short
term
goal).



Step
7:

Find
a
willing
client
and
walk
through
a
chain
analysis
of
the
feelings
and
thoughts
that
may
have

interfered
with
the
incompletion
of
the
homework.
What
were
the
barriers?
What
thoughts,
feelings
or
practical

aspects
of
the
client’s
life
do
they
believe
stand
in
the
way
of
clarifying
and
following
through
with
meaningful

goals.


Closure of Session:


End
with
a
discussion
of
willingness
to
continue
to
proceed
with
clarifying
values
and
following
through
with
goal

completion.
This
discussion
may
focus
on
the
following
points:



1)
Perceived
barriers
to
values


2)
Clients’
experiences
thus
far
with
values
clarification
and
committed
action


3)
Confusion
about
this
piece
of
therapy


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 72


4)
Accessing
social
support
(i.e.
via
their
peer
partner,
family,
friends
and
treatment
providers)
in
the
process
of

committed
action.


Moving
Ahead
with
Committed
Action



Goals,
Purpose
and
Process
Suggestions
for
Sessions
16‐18

The
following
three
group
sessions
are
the
last
in
this
protocol.
The
following
are
goals
for
these
sessions:



1.
To
continue
clarification
of
value‐based
goals.




2.
To
identify
barriers
to
committed
action.


3.
To
increase
committed
action
in
goal‐completion,
building
patterns
of
committed
action.



4.
To
increase
generalization
of
skills
for
valued‐living,
with
intention
of
continued
committed
action
upon

completion
of
the
protocol.



The
Purpose
of
Committed
Action


The
purpose
of
targeting
committed
action
is
to
increase
a
client’s
range
of
behaviors,
making
it
broader
and

more
meaningful.
Committed
action
in
ACT
is
following
through
with
goals
(doing
things)
that
are
aligned
with
an

individual’s
personal
values.
Enhancing
the
vitality
or
meaningfulness
of
one’s
life
is
the
ultimate
goal
of
ACT.
The

meaning
and
joy
found
in
committed
action
to
values‐based
living
is
the
“why”
of
walking
through
pain.



Addressing
other
Core
Processes
in
Committed
Action


In
order
to
live
a
vital,
meaningful
life,
a
client
must
utilize
all
six
core
processes
involved
in
the
ACT
model.

Committed
action
requires
willingness
from
the
client
to
actually
change
some
behavior.
As
clients
apply
other

ACT
core
processes
and
become
aware
that
avoidance
behaviors
are
not
workable
for
a
desired
outcome
and
new

behavioral
directions
exist,
a
choice
point
becomes
available.
However,
approaching
new
goals
(or
any
new

behavior)
often
evokes
difficult
feelings.
Present
moment
focus
enables
clients
to
notice
what
they
are
feeling
and

make
the
choice
to
approach
versus
avoid
that
feeling
state
in
the
service
of
their
values
and
new
behaviors.

Therefore,
acceptance
of
feelings
that
exist
in
the
absence
of
control
strategies
will
be
necessary,
at
least
to
some

degree,
in
order
to
move
in
a
new,
value‐based
direction.
The
ability
to
notice
the
consistent
sense
of
self
in

various
contexts
during
this
process
will
be
important.
Noticing
self
in
context,
client
will
be
able
to
say
“I
watched

myself
make
a
choice
to
fall
back
on
the
old
behavior”,
or
“I
just
made
a
new
choice,
and
can
reflect
on
how

enjoyable
it
was
even
though
I
was
also
feeling
anxious”.
The
ability
to
notice
the
inevitable
approach/avoid

variation
with
respect
to
new
behaviors,
emotions
and
thoughts
can
allow
clients
to
notice
patterns
of
committed

action
versus
avoidance.
Finally,
values
clarification
is
an
ongoing
process.
So,
as
clients
are
building
patterns
of

committed
action,
some
re‐clarification
will
occur.
Something
that
one
thought
would
be
meaningful
might
turn

out
to
only
be
a
story
in
the
mind.
Ultimately,
clients
will
need
to
refocus
and
recommit,
again
and
again,
to
what

is
truly
meaningful
in
life.



Suggestions
for
Group
Process

A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 73


Just
like
the
other
ACT
core
processes,
committed
action
is
an
ongoing
process.
It
occurs
last
in
this
protocol,

however
clients
have
already
begun
committed
action
in
the
prior
three
sessions.
In
values
clarification,
clients

were
given
a
few
homework
assignments
aimed
at
clarifying
meaningful
goals
and
trying
out
some
commitment

to
those
goals.
In
the
final
three
sessions,
it’s
time
to
focus
on
barriers
to
either:
A)
finding
meaningful
goals
and

B)
following
through
with
commitment
to
those
goals.
At
this
juncture,
clients
may
not
have
yet
identified
goals

that
hold
true
meaning
and
vitality.
If
not,
now’s
the
time
to
focus
on
helping
them
find
at
least
one
area
of
life

that
holds
meaning
and
mapping
out
some
manageable
goals.
If,
on
the
other
hand,
clients
have
found
an
area
of

life
that
is
meaningful,
now’s
the
time
to
target
commitment
to
goals
they’ve
created.
Some
work
may
need
to
be

done
in
changing
goals
to
make
them
more
meaningful
or
attainable.
However,
other
barriers
should
be
assessed,

including:
Thoughts,
feelings,
avoidance
strategies.
As
the
therapist,
you
are
bringing
together
the
six
core

processes
to
assist
clients
in
generalizing
new
behaviors
outside
the
therapy
room.
Peer
facilitation
will
also
be

used
as
a
tool
for
behavioral
generalization
as
well
as
coaching
and
support.



As
in
other
sessions,
it
will
be
important
to
work
on
reorienting
clients’
attention
to
the
present
moment,

especially
for
those
not
participating
in
the
group
exercises.
For
those
not
completing
homework,
it
will
be

important
to
identify
specific
barriers
to
committed
action
for
that
client.
You’ll
want
to
do
this
in
group
with
the

client.
That
is,
instead
of
guessing
at
the
barrier,
it’s
useful
to
conduct
a
quick
chain
analysis
with
the
client
in

group
to
identify
the
barrier.
Other
clients
may
identify
with
the
barrier
and
this
can
serve
as
a
point
of
social

support
and
empathy.
In
situations
where
clients
agree
upon
a
common
barrier
to
homework
completion,

spending
a
few
minutes
generating
solutions
to
the
barrier
in
group
is
useful.



To
review,
in
the
next
three
sessions
you’ll
be
doing
five
primary
things
in
the
next
three
sessions.
These

processes
will
repeat
over
the
course
of
three
sessions,
and
often
in
one
session
with
clients.


1)
Assisting
clients
in
continued
values
clarification




2)
Adjusting
goals
to
meet
the
client’s
specific
life,
needs
and
practical
limitations


3)
Conducting
chain
analyses
to
identify
specific
barriers
to
completion
of
goals



4)
Targeting
perceived
barriers
with
acceptance


5)
Identifying
and
pointing
out
the
choice‐points
of
valued‐living
versus
avoidance




The
three
sessions
of
committed
action
will
involve
these
five
processes
during
treatment.
In
group
exercises,

metaphors,
homework
assignments
and
peer
to
peer
interaction
will
be
utilized
to
target
these
treatment

processes.





A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 74


Session
16:
Turbulence
in
Flight:
What
Makes
for
Rough
Ride?

Purpose: 


The
purpose
of
this
session
is
to
identify
specific
barriers
clients
face
in
completing
their
goals.
You’ll
use
a
soft

chain
analyses
to
identify
variables
that
may
be
interfering
with
clients'
work
on
values
and
goals.



Preparation:

Posters
w/the
different
types
of
barriers—thoughts,
emotions,
physical
sensations,
practical
issues

3X5
cards/pens
(or
cards
printed
with
various
common
examples
of
the
different
types
of
barriers)

Client's
bags
and
a
large
bag
(pillow
case)

Various
sized
lead
weights


Copies
of
the
worksheet,
“Goals
and
Barriers”


Orientation
to
Group:

Ring
the
bell


Review/Introduce
the
Session:




Ask
if
anyone
has
worked
with
their
partner
or
on
their
own
to
set
or
complete
a
short
term
goal
that
moved

them
a
little
along
their
meaningful
life
direction?

Have
those
that
completed
a
goal
share
what
it
was
and
what

it
was
like
to
complete
it.


Ask
those
that
completed
their
goal
if
any
that
thing
came
up
that
seemed
to
get
in
the
way
of
choosing
their
goal

and
completing
it?



Generally
ask
those
that
didn't
complete
a
goal
if
things
seemed
to
come‐up
that
got
in
their
way
of
finding
a

meaningful
direction
to
take
in
life,
or
in
selecting
&
completing
a
goal
along
that
path?


Exercise
1:
Meaningful/Valued
Living:
Barriers
&
How
to
Hold
Them


Rationale:

This
exercise
focuses
on
further
exploring
the
concept
of
barriers
to
moving
in
a
meaningful
life

direction
(specifically
completing
a
goal
along
that
path),
identifying
them
in
a
concrete
manner,
emphasizing
the

value
in
noticing
them,
and
re‐introducing
willingness
to
"have"
perceived
barriers
&
continue
moving.



Introduction:



Say
something
like
"Isn't it true that things nearly always seem to come up and get in the way when we try 
something new and set goals along that path…, even if it's a meaningful path we really want?  Things get in the 
way & barriers seem to be a part of life. When they block us from moving and completing a goal it can be 
disappointing/frustrating. However, in some ways not completing a goal is just as valuable as completing it. When 
we don't complete it we have the chance to get to know ourselves better, if we're willing to look at what got in the 
way of meeting the goal.  This can actually open up more choices for us. Many different types of barriers can come 
up when we set and move towards completing a goal."



*Background
Information
for
the
Leaders:


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 75


The
following
are
common
barriers,
from
an
ACT
perspective:



Thoughts:
Any
thought
that
the
client
uses
as
a
reason
for
not
completing
the
goal.
These
will
typically
be
what

the
client
says
“ABOUT”
why
he/she
did
not
complete
the
homework
(i.e.
I
just
didn’t
think
that
I
could
do
it).

Then
you
can
identify
“I
couldn’t
do
it”
as
the
thought
that
stood
in
the
way.



Feelings:
Any
feelings
that
the
client
perceives
stand
in
the
way
of
completing
a
task
(i.e.
I
was
too
anxious,

scared,
depressed,
etc.).



Physical
Sensations:
Any
physical
sensation
that
a
client
may
find
uncomfortable
or
aversive
(i.e.
I
was
too
tired,

nauseas,
tense,
etc.)



Avoidance
Behaviors:
Any
behavior
serving
the
function
of
experiential
avoidance


Practical
Barriers:
These
include
money,
time
and
skill
level.
These
practical
barriers
are
sometimes
not
accurate

(i.e.
the
client
is
actually
using
the
practical
“I
didn’t
have
time
because
I
had
to
do
_____”
as
an
avoidance
move

in
the
service
of
avoiding
the
anxiety
associated
with
completing
the
new
goal.
In
that
case,
you’d
want
to
ask

what
feeling
was
associated
with
thinking
about
completing
the
goal
just
before
the
client
found
that
he/she
did

not
have
time.
Therefore,
the
feeling
that
was
avoided
would
be
earlier
in
the
chain
analysis,
preceding
the

activity
that
the
client
did
instead
of
the
goal.



Alternately,
the
client
may
actually
have
chosen
a
goal
that
was
not
fitting
for
their
current
life
circumstance.
This

in
itself
may
have
been
an
avoidance
move.
If
there
is
a
pattern
of
choosing
goals
that
are,
ultimately
not
fitting
to

the
client’s
resources,
then
you
may
want
to
assess
for
an
avoidance
pattern.
Alternately,
if
this
is
a
one‐time

occurrence
you
may
suggest
the
client
find
an
alternate
goal
that
is
more
fitting
to
their
resources.



Step
1:

Introduce
the
main
types
of
barriers
by
taping
the
posters
to
the
wall.


Step
2:

Hand
out
3x5
cards/pens
to
clients
and
ask
them
to
identify
3
barriers
they
experienced
when
they
were

trying
to
set
or
complete
their
goal.
Have
them
write
these
on
3
cards
identifying
on
the
card
the
type
of
barrier
it

is—thought,
physical
sensation,
etc…
(or
pick
pre‐printed
cards
that
fit
for
them).


Step
3:
Ask
if
anyone
is
willing
to
discuss
their
experience
of
attempting
to
set/complete
a
new
goal.



Step
4:
With
that
client
volunteer:


















a.
Ask
him/her
what
his
short
term
goal
is.
If
he
doesn't
have
one,
ask
if
he
has
was
able
to
find
a

meaningful/valued
life
direction
he
wants
to
pursue.



b.
Ask
if
the
barriers
he
listed
on
his
cards
were
the
ones
that
interfered
with
his
attempt
to
set
or

complete
a
goal
(find
a
meaningful
life
direction)
these
past
few
weeks?
If
not,
do
a
chain
analysis
to
identify
the

barriers
he
experienced
related
to
his
not
completing
the
work
assigned
over
the
last
few
weeks—finding
a

meaningful
life
direction
or
setting/completing
a
goal.

c.
Ask
him
to
assign
a
weight
in
pounds
for
each
of
the
barriers
identified
based
on
how
much
they
believe

that
barrier
or
how
much
it
consumed
their
time
or
distracted
them.


d.
Show
them
their
little
bag
that
they
made
that's
holds
some
of
their
thoughts
identified
in
past

sessions.
Then
show
them
the
big
bag.
Place
their
little
bag
in
the
big
one
(explaining
that
it
represents
his
small


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 76


bag)
,
along
with
the
card
identifying
each
current
barrier
&
the
weights
that
he
attributed
to
each
(nice
to
have

another
group
member
help
with
this).
Have
him
hold
the
bag…


e.
Discuss
with
him
and
the
group
his
current
situation
with
such
questions
as:


‐‐Might
these
barriers/weight
slow
or
stop
his
movement
toward
his
goal
setting/completion?


‐‐What
could
he
do
with
the
weight?
Can
you
really
get
rid
of
it?
What
has
he
&
others
tried
(don't
want,
got
it

concept)


‐‐Is
this
weight
new;
did
it
just
start
when
he
began
working
on
setting/completing
a
goal
this
past
few
weeks?

How
long
has
he
been
carrying
this
weight?


‐‐Ask
if
might
their
be
some
choice
now
they
are
more
aware
of
these
barriers?
i.e.
solve
a
practical
issue,
hold

thoughts/feelings
&
continue
to
move,
break
a
goal
down
into
smaller
steps,
etc.

*Notice
if
his
co‐pilot
has
more

thoughts
about
having
choice?

f.
Sample
the
client's
willingness:



‐‐Ask
him
if
he
might
be
willing
to
consider
his
choices…consider
having
barriers
&
still
fly?


‐‐Ask
him
to
Rate
his
WILLINGLESS
ON
A
1‐10
SCALE…1
=
none,

10
=
a
lot


Step
5:
Repeat
steps
3
&
4
with
1‐2
more
clients,
as
time
permits.



Step
6:

Introduce
&
hand
out
homework
“Goals
and
Barriers”,
ask
members
to
identify
their
partners
(make

assignments
as
needed),
&
ask
them
to
meet
and
complete
this
handout
before
the
next
group.




Closure of Group 

Ask
clients
to
set
another
meeting
w/their
partner
this
week
(ask
members
to
identify
their
partners
(make

assignments
as
needed).
They
will
be
completing
another
short
term
goal
this
week
with
the
handout
“Goals
and

Barriers”.
They
may
repeat
the
goal
that
they
have
chosen
in
prior
weeks,
or
they
may
work
with
their
partner

outside
of
group
to
choose
a
new
goal.



Give
clients
the
handout
“Goals
and
Barriers.”
Instruct
clients
that
they
should
complete
this
worksheet
with
their

partner
after
they
complete
their
goal
during
their
week,
but
before
our
next
group.




A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 77


Session
17:


Willingness
in
Action


Purpose:
The
purpose
of
this
session
is
to
teach
the
concept
of
willingness
(i.e.
to
move
in
a
valued
direction
even

with
perceived
barriers).



Preparation:

Prior
to
starting
group,
tape
to
the
wall
the
posters
of
the
4
types
of
barriers
used
last
week

Copies
of
the
worksheet,
“Commitment
to
a
new
Path”


Orientation
to
Group:

Ring
the
bell


Review/Introduce
the
Session:

Check
in
with
clients
as
to
who
completed
the
peer‐peer
assignment.
Ask
those

peers
who
did
complete
the
work
to
share
it
with
the
group
(i.e.
share
the
goal
that
was
completed,
then
share

which
barriers
they
endorsed,
and
their
willingness
rating
to
work
on
the
goal
bringing
the
barriers
along).


This
will
provide
an
introduction
to
the
concept
of
willingness.


Ask
clients
what
they
understand
from
the
worksheet
about
the
concept
of
willingness.
What
is
it?
What
have

they
heard
about
it?
(Elicit
feedback
from
clients).



Exercise
1:
Flying
in
a
Meaningful
Direction
with
Turbulence:
Are
You
Willing?


Rationale:
Clients
are
aware,
at
least
to
some
degree,
of
existing
barriers
at
this
juncture.
Teaching
the
concept
of

willingness
provides
a
tool
for
how to
commit
to
and
proceed
in
a
meaningful
life
direction
even
with

uncomfortable
thoughts,
feelings
and
other
perceived
barriers:
being
willing
is
taking
action
in
the
presence
of

discomfort.


Preparation:

Check
in
with
the
clients
as
to
who
has
a
goal
but
has
struggled
this
past
week
to
complete
it.
Select

or
ask
for
a
volunteer
to
be
the
pilot
for
a
willingness
exercise.



Step
1:
Ask
the
client
to
state
the
goal
he/she
chose,
which
has
not
yet
been
completed.
Set
up
chairs
like
seats

on
an
airplane
and
have
the
pilot
take
his/her
seat.



Step
2:
Review
the
reasons/barriers
listed
on
the
homework
assignment
(&
posted
on
the
wall)
aloud
with
the

pilot.
Asking
him/her
to
say
“yes”
or
“no”
to
the
barriers,
with
the
point
identify
the
their
primary
barriers
(up
to

three).
As
therapist,
you
should
identify
the
category
of
barrier
(e.g.
are
there
thoughts
getting
in
the
way,

feelings,
or
practical
things
like
money,
time
or
other
people)?


From
this
point,
you’ll
want
to
flexibly
address
willingness
with:


1)
defusion
(if
the
primary
barrier
is
fusion
to
thoughts),


2)

acceptance
(if
the
primary
barriers
are
unwanted
feelings/physical
sensations?),

3)

problem
solving
(if
the
primary
barriers
are
practical
issues)
or,
?

4)

some
combination
of
the
above.


Step
3:
Intervening
on
barriers
with
willingness

A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 78


A. If the primary barriers are thoughts:  

As
the
pilot
identifies
thoughts
that
are
barriers,
invite
other
clients
to
represent
the
copilot
&
passengers,
come

up
and
take
a
seat
on
the
plane,
and
say
aloud
thoughts
that
may
have
served
as
barriers
(i.e.
“this
goal
really
isn’t

important).


Practice
Defusion:

As
other
clients
state
thoughts
the
client
may
have,
ask
the
client
to
rank
willingness
to
some

of
the
following
questions:


“Can you notice these thoughts as statements from you co‐pilot or passengers?  

“Are you willing to hear these thoughts and fly the plane in the new direction by sometimes completing difficult 
new goals?” 

B. If the primary barriers are feelings:  

Conduct
a
chain
analysis
with
the
pilot:



Ask
when
the
feeling
arose
with
respect
to
completing
the
goal
&
if
this
the
first
time
they've
felt
it.

Ask
the
client
“are
you
willing
to
have
that
feeling
if
_____________”
(fill
in
the
blank
with
something
big
(i.e.
if

you
could
win
a
million
bucks).
What
would
need
to
happen
for
you
to
be
willing
to
have
some
of
that
feeling?



*Encourage
Emotional
Experiencing:
As
you
conduct
the
chain
analysis,
notice
if
the
client
experiences
the
feeling

in
session.
Sit
quietly
with
the
client
as
these
feelings
emerge.



Ask
the
client:
I’m noticing that even as we talk, you are experiencing some of the feeling you do not 
want. “Are you willing, right now in this moment, to have this feeling?” 

Discuss
avoidance:
If
the
client
is
not
willing
to
sit
with
the
feeling,
or
if
the
feeling
does
not
emerge
move
to

discussing
avoidance:



Ask
the
client:
If
by
NOT
completing
the
goal
did
he/she
completely
avoid
the
feeling?



The
general
message
to
this
exercise
should
be:
If
you
don’t
want
it,
you’ve
got
it.
So,
if
you
already
feel
anxious,

depressed,
etc,
can
you
have
THAT,
AND
complete
a
new
goal
WITH
that
feeling.
This is willingness. 

Additionally,
as
thoughts
emerge
during
this
"emotion"
chain
analysis,
invite
other
clients
to
represent
the
copilot

&
passengers,
come
up
and
take
a
seat
on
the
plane,
and
say
aloud
these
thoughts
serving
as
barriers.


C. If the primary barriers are practical ones (i.e. time, money, other people):  

Try
some
problem
solving:
Make
sure
that
the
goal
set
isn’t
practically
unfeasible.
In
problem
solving,
identify
the

practical
barrier.
Then
clients
and
therapist
may
elicit
ideas
to
ameliorate
the
practical
issue.



Use
Defusion
if
More
Reason
Giving
Occurs:
If
the
client
begins
to
list
more
“reasons”
in
response
to
problem

solving,
treat
the
reasons
as
thoughts.
You
may
want
to
stop
the
client
and
ask
permission
for
the
co‐pilot
or

passengers
to
repeat
the
“reasons”.



Use
Acceptance
for
Difficult
Emotions:
If
the
client
appears
to
become
distressed
during
problem
solving,
STOP

PROBLEM
SOLVING
AND
MOVE
INTO
THE
EMOTION,
encouraging
the
client
to
experience
it.
The
unwanted

emotion
is
likely
a
barrier
to
committed
action.

A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 79


D. Example of working with a client who presents a practical barrier: 

The
goal:
Applying
for
a
job.


The
reason/barrier:
The
client
states
his
reason
as
being
“I
didn’t
have
a
ride
to
the
place
where
I
was
supposed

to
file
the
job
application.



Problem
solving:
The
therapist
should
first
try
some
problem
solving,
for
example:



“Could you have taken the bus?”  

The
client
states:
“No, because I didn’t have a bus schedule and the bus stop is over a mile from my 
home”.  

Provide
more
suggestions:
Clients
and
therapist
can
provide
more
suggestions.



“Could you have asked a PST for a bus schedule?”  

The
client
states:
“I didn’t want to ask for help with this. It seemed easier to just not do it”. 


Identifying
a
Thought
or
Feeling:



At
this
juncture,
it’s
clear
that
there
is
a
barrier
(i.e.
either
a
thought
or
a
feeling)
standing
in
the
way
of
goal

completion.
Therefore,
the
therapist
should
shift
to
identify
the
thought
or
feeling.



Ex:
Therapist:
“How does it feel to ask for help? Or, what does your co‐pilot say when you consider asking for 
help?”


Targeting
a
core
process:
Once
a
thought
or
a
feeling
is
identified,
defusion
or
acceptance
should
be
targeted.



Finally,
a
new
goal
can
be
set.
In
this
example,
the
new
goal
may
be
to
ask
a
PST
for
a
bus
schedule
this
week.



Ask
the
client
then,
how
willing
is
he/she
to
complete
the
new
goal
even
with
the
feelings/thoughts
that
will

surely
arise
in
doing
this?
Ask
him/her
to
provide
a
ranking.


Closure
of
Session



Following
this
exercise,
ask
clients
who
did
not
complete
the
worksheet
last
week
to
do
so
this
week.
Remind

clients
that
the
next
group
will
be
the
last
in
the
series.
However,
valued
living
through
goal
completion
is
an

ongoing
part
of
living.
Therefore,
further
identification
of
meaningful
goals
and
barriers
to
achieving
those
goals

will
be
part
of
work
involved
in
the
ACT
group.



Give
clients
the
peer
to
peer
worksheet:
“Commitment
to
a
new
Path”
to
complete
and
return
next
session.
IF

there
is
time
in
the
group,
have
peer
partners
schedule
a
time
this
week
to
meet
to
complete
the
worksheet.


A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 80


Session
18:

Committed
to
a
Valued
Path

Purpose:
The
purpose
of
the
final
session
is
to
further
encourage
commitment
to
valued
living
via
public

commitment
statements.
These
statements
include:
1)
The
meaningful/valued
direction
the
client
is
moving

towards
2)
A
short
term
and
long
range
goal
3)
barriers
which
will
arise
4)
The
degree
of
willingness
the
client
has

to
move
towards
completing
the
goals,
even
with
the
barriers.


Prepare:

Bring
the
White
Board,
Committed
Action
Posters?


Orientation
to
Group:

Ring
the
Bell


Review/Introduce
Session:

Check
in
with
clients
about
who
completed
the
peer
to
peer
assignment.
Reinforce

those
who
completed
it.



In
this
session
the
initial
aim
is
homework
completion:




 For
those
who
did
not
complete
the
homework,
the
task
of
this
session
will
be
to
complete
parts
1
and
2

the
worksheet:
“Commitment
to
a
Valued
Path”
with
their
peer
in
pairs.
For
those
who
did
complete
the

homework,
they
will
be
asked
to
join
a
pair
to
assist
with
completion.



Exercise
1:

Commitment
Statements


Rationale:

A
public
commitment
statement
is
an
opportunity
to
share
the
work
done
by
peer
pairs,
a
time
for
the

group
to
provide
support,
and
a
means
of
facilitating
accountability
for
continued
valued
working.


It
will
be
important
to
allow
enough
time
for
each
client
in
the
group
to
provide
a
brief
commitment
statement

based
upon
Part
2,
Session
17
Worksheet:
Commitment
to
a
Valued
Path


Therefore,
time
for
in
session
completion
should
be
weighed
with
time
needed
for
each
client
to
provide
their

commitment
statement.
If
necessary,
clients
can
make
a
commitment
statement
without
having
completed
the

worksheet.
Therapists
and
the
group
may
provide
assistance
to
walking
the
client
through
the
worksheet
as
they

make
their
commitment
statement.


Special
Instructions
for
Commitment
Statements:



1.
Clarify
with
client
the
reasons
for
commitment
statements,
as
stated
in
the
rationale.



2.
Commitment
statements
are
a
reading
of
Part
2
of
the
Worksheet.
This
includes
the
following
specific

components.
Clients
may
refer
to
their
worksheet
when
answering
the
following
therapist‐prompted
questions.
If

it
is
helpful,
these
points
may
be
written
on
the
White
Board.



 A.
What
is
the
meaningful
life
direction
you've
chosen?




 B.
What
is
your
short
term
goal?


C.
What
is
your
long
term
goal?



 D.
What
are
three
barriers
likely
to
arise
in
efforts
to
complete
these
goals?



A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 81


E.
Where
is
your
willingness
(on
a
scale
of
0‐10)
to
work
on
completing
the
goals,
even
with
the
barriers?



F.
What
would
help
you
in
this
process?



2.
Ask
that
clients
show
support
and
assistance
to
clients
during
commitment
statements
(i.e.
support
for
the

client’s
stated
goals,
and
assistance
if
the
client
gets
“stuck”
in
completing
the
worksheet
in
their
commitment

statement).
This
is
different
from
“answer
giving”,
but
clients
may
offer
suggestions
to
the
client
as
can
the

therapist.


3.
Clarify
with
clients
that
finding
and
moving
in
meaningful
directions
is
an
ongoing
endeavor.

You,
as
therapist,

may
decide
to
provide
a
commitment
statement
to
the
group
about
your
role
as
therapist
(most
helpful
for
the

therapist
to
model
this
and
go
first).
Or,
you
can
provide
an
example
from
your
life,
about
an
area
of
valued
living

on
which
you
are
continuing
to
work.
Many
ACT
therapists
have
often
found
providing
their
own
commitment

statement
to
the
group,
participating
in
the
activity,
facilitates
client
willingness.



Closure
of
the
group



Group
closure
should
end
with
the
commitment
statement
from
the
last
client.
There
is
no
need
to
“wrap
up”
or

“end”.
Ending
the
group
with
the
last
commitment
statement
(instead
of
an
ending
exercise)
models
that
the

work,
indeed,
never
ends.


If
you
desire
a
concluding
remark,
something
along
the
lines
of
the
following
statement
may
be
useful:


 “Thank you for your willingness to share what you value, your pain and your work with us; we encourage you to 
continue moving in a meaningful life direction, and hope that this group can continue to assist you in your work 
along this path.” 

A.
Pearson,
Ph.D.
&
R.
Tingey
Ph.D.
 
 82