ACT for Depression and Anxiety Group - Cornell University Counseling and Psychological Services

Introduction - These materials accompany the ACT for Depression and Anxiety Group...
These materials accompany the ACT for Depression and Anxiety Group developed by Matt Boone at Cornell University's Counseling and Psychological Services. It is a 10 session college counseling center group which combines didactic elements, mindfulness exercises, experiential exercises, group discussion/process, and homework (called LIFE Exercises). The protocol described here is very close (about 90%) to what was used in Matt Boone's pilot study of a transdiagnostic ACT group in college counseling. A few homework worksheets have been removed to give participants less to do between sessions, and the order of a some elements have been changed slightly.

The group is meant to fit within a single semester. The first half of the semester covers the six processes of psychological flexibility. The second half focuses on mobilizing psychological flexibility in the service of values-driven committed action – both inside the group, as members interact with one another, and outside the group in the students' lives. The second half looks a little bit more like traditional group therapy – group leaders are encouraged to incorporate the interpersonal group process into conversations about acceptance, mindfulness, and values.

The materials were collated and revised by Matt Boone and Cory Myler during the 2011-2012 academic year. Feel free to contact either Matt or Cory about any aspect of the group. Matt can be reached at matthewsboone@gmail.com. Cory can be reached at cory.myler@gmail.com.

Group Format
Each group meeting is organized roughly as follows:
● opening mindfulness exercise
● review of LIFE Exercises from the previous week
● didactic portion with group discussion
● experiential exercise with group discussion
● further group discussion
● assigning LIFE exercises for next time
The didactic portion ends in the fifth session and is reinforced by the readings.

The progression of the group throughout the semester is roughly organized around the six processes of psychological flexibility. These are defusion, acceptance/willingness, contact with the present moment, self as context (called the "observing self" in the group), values, and committed action.

The order is as follows:
● session 1: "control is the problem" and contact with the present moment
● session 2: defusion
● session 3: acceptance/willingness
● session 4: values
● session 5: observing self
● session 6: committed action
● session 7-10: all processes, with a focus on building greater patterns of committed action in the service of values

Background
It is helpful if you have been to at least one ACT training and you are familiar with some core ACT texts. At minimum you should read ACT Made Simple, because many of the group's didactic elements are drawn from it, and The Happiness Trap, because readings from it are used as homework. Other good texts are The Mindfulness and Acceptance Workbook for Depression, Learning ACT, Mindfulness for Two, Get Out of Your Mind and Into Your Life, Acceptance and Commitment Therapy: The Process and Practice of Mindful Change, and The Mindfulness and Acceptance Workbook for Anxiety. All of these influenced the creation of the group. Full citations of these texts are included at the end of this document..

Session Outlines
Outlines for each group session are included. For the first five sessions, the outlines give instructions which accompany the PowerPoint slides. The outlines are far more detailed in the first few sessions, mostly because the majority of the psychoeducation happens then, but partly because limitations on time and resources have prevented writing everything out extensively. You should use your best judgment and your experience with leading groups, but feel free to contact Cory or Matt with questions.

Power Points
As noted above, PowerPoint is used to introduce didactic elements in the first five sessions. Beware of relying on them too much. Remember: ACT draws on metaphors and experiential exercises just as much as it relies on education. Most of the text in the PowerPoints comes directly from ACT texts. Citations are included where appropriate, but some may have been forgotten. The pictures are all from Google images, and their copyright is uncertain.

Readings
The readings are not included. Group members should be encouraged to buy The Happiness Trap, and the short excerpt from the Mindfulness and Acceptance Workbook for Depression assigned in session 3 can be photocopied and passed out. Optional additional readings are also excerpted from The Acceptance and Mindfulness Workbook for Depression. If you assign the optional readings, consider encouraging students to buy the book. These readings expand on the concept of defusion. The Acceptance and Mindfulness Workbook for Depression extensively explores defusion, the function of thinking, and potential pitfalls in getting wrapped up in the mind.

Worksheets and Handouts
Most worksheets and handouts are adapted from ACT Made Simple and The Happiness Trap. Every attempt has been made to cite original sources where appropriate. The excerpt from The Acceptance and Mindfulness Workbook for Depression includes a worksheet which is completed for homework between sessions 3 and 4.

Mindfulness MP3s
Four mindfulness exercises that are used for homework are included in MP3 form. Some of them are also used as exercises to mark the beginning of group sessions. (However, group leaders are encouraged to lead the exercises themselves rather than playing the MP3s in group.) Because the recordings were created in an amateur home studio, they sound fine through speakers, but there is some background noise when you listen to them on headphones. They are designed to be short because busy students often will not do lengthy mindfulness exercises for homework. Keeping them short hopefully makes it more likely that they will do them.

Scripts for all of them except "Brief Mindfulness" can be found in the ACT literature. The script for "Brief Mindfulness" was improvised by Matt Boone, but it's very close to other short mindfulness exercises in the literature. It is meant as a brief instruction on mindfulness, as well as a mindfulness exercise in itself. The scripts for "Leaves on a Stream" and "Acceptance of Thoughts and Feelings" are taken from the Mindfulness and Acceptance Workbook for Anxiety. Both can also be found in Acceptance and Commitment Therapy for Anxiety Disorders and "Leaves on a Stream" can be found in many other ACT texts. "Willingness Exercise" is an extensive acceptance exercise taken from ACT Made Simple. (It is similar to "physicalizing" in the ACT literature. It is assigned for homework a number of times throughout the group to facilitate exposure to feared internal stimuli like thoughts and feelings. Scripts for some of the other group's mindfulness exercises are included with these materials. They are similar to mindfulness exercises found in the ACT literature.

Experiential Exercises
Detailed instructions for many experiential exercises are included, but some are not. For example, nothing is written about "Eyes On," but there is information about it in many ACT texts. The same goes for "Take Your Mind for a Walk."

Notes to Group Leaders
● Be flexible. Feel free to jettison the psychoeducation or any experiential exercise if it does not feel appropriate for a particular group session. The most important thing is that participants get to encounter and understand, both experientially and intellectually, what psychological flexibility is like. Too much structure can get in the way of the group process.
● Working in the "here and now." Despite the psychoeducation elements, some really powerful "here and now" work can be done in this group if there is space left open for it. The ACT vocabulary gives students a way to talk about what they're experiencing in the moment and helps group members understand their reactions as part of their histories, not what others are "doing" to them. Doing this work is not really covered in these materials – draw on your training in group therapy. If you need further reading, see the chapter below, and especially consult Yalom's seminal work, The Theory and Practice of Group Psychotherapy.
● The book chapter "Acceptance and Commitment Therapy (ACT) in Groups" is included as optional reading for group facilitators. It presumes the reader has already had an introduction to the six processes of psychological flexibility.
● Please feel free to e-mail Matt or Cory with any questions.

Cheers!

Resources
Boone, M. S., & Manning, J. (2012). A pilot study of an Acceptance and Commitment Therapy group for anxiety and depression in a college counseling center. Manuscript in preparation.

Boone, M. S. , & Canicci, J. (In press). Acceptance and commitment therapy (act) in group. In Pistorello, J. (Ed.). Mindfulness and Acceptance on the College Campus. Oakland, CA: New Harbinger.

Luoma, J., Hayes, S. C., & Walser, R. (2007). Learning ACT. Oakland, CA: New Harbinger.

Eifert, G. H., & Forsyth, J. P. (2005). Acceptance and commitment therapy for anxiety disorders: a practitioner's treatment guide to using mindfulness, acceptance, and values-based behavior change strategies. Oakland, CA: New Harbinger.

Forsyth, J. P., &, Eifert, G. H. (2007). The mindfulness and acceptance workbook for anxiety. Oakland, CA: New Harbinger.

Harris, R. (2010). ACT made simple. Oakland, CA: New Harbinger.
Harris, R. (2008). The happiness trap. Boston, Massachusetts: Shambhala.
Hayes, S. C., & Smith, S. (2005). Get out of your mind and your life: The new acceptance and commitment therapy. Oakland, CA: New Harbinger.

Hayes, S. C., Strosahl, K., & Wilson, K. G. (2011). Acceptance and commitment therapy: The process and practice of mindful change (2nd edition). New York: Guilford Press.

Strosahl, K., & Robinson, P. (2007). The mindfulness and acceptance workbook for depression. Oakland, CA: New Harbinger.

Walser, R. D., & Pistorello, J. (2004). ACT in group format. In S. C. Hayes & K. D. Strosahl (Eds.), A practical guide to acceptance and commitment therapy (pp. 347-372). New York: Springer.

Yalom, I. (2005). The theory and practice of group psychotherapy (5th ed.). New York: Basic Books.