ACT Therapy for Psychosis Group Protocol

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.  
 
 
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.  
 
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 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. 
 
 
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)
 
“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?
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?”

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?”

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).  
 
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. 
 
 
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.”
 
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.  
 
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.  
 
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.  
 
 
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 
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:  
 
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. 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
 
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. 
  
 
 
 
Defusing from the Noise:  Living With Thoughts and Voices 
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.  
 
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.  
 
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.  
 
 
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.  
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:  
 
“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!
 
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.  
 
 
 
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.  
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.  
 
 
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 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 9: At this time ask clients to consider question #4 on the three by five card, and to fill in the blank.  
Group Closure:
 
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…)? 
 
 
 
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  
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
 
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.  
 
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.  
 
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 Review of Acceptance:  
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 
 
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 
 
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. 
 
 
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.  
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.  
 
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?  
 
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 
 
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.  
 
 
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. 
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.  
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.  
 
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.  
 
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?”
 
 
 
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. 
 
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.  
 
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.  
 
 
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. 
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 
 
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; 
 
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 Review of Self as Context:  
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.) 
 
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.  
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.  
 
 
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. ”
 
“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. 
 
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.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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.   
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 
 
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
 
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.  
 
 
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.  
   
 
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 
 
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 
 
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   
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.  
 
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.  
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.  
 
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.  
 
 
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 
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. 
 
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. 
 
"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)? 
 
 
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” 
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
 
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.”
 
“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.  
 
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.   
 
 
 
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”  
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  
 
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).  
 
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.  
 
 
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. 
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?”  
 
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  
 
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   
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.  
 
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.   
 
 
 
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: 
 
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 
 
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.  
 
 
 
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. 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. 
 
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. 
 
 
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? 
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?  
 
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.”
 

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Acceptance and Commitment Therapy

Anxious   Scared    Sad  Depressed  Joyous     Excited   Disappointed   Peaceful

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Acceptance and Commitment Therapy

Anxious Scared Sad Depressed Joyous Excited Disappointed Peaceful

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Acceptance and Commitment Therapy 

Anxious   Scared    Sad  Depressed  Joyous     Excited   Disappointed   Peaceful 