ACT therapy session notes: an outline built around the six processes, with a filled-in example

What an ACT note needs to track

Acceptance and Commitment Therapy (ACT) was described by Steven C. Hayes, Kirk D. Strosahl and Kelly G. Wilson in a book published in 1999 and revised in 2011. Its aim is psychological flexibility. The Association for Contextual Behavioral Science (ACBS), the scientific society for ACT, defines it as the ability to contact the present moment more fully, and to change or persist in a behaviour when doing so serves what matters to the person.

So the work does not aim first at making a painful thought or emotion go away, but at making sure it no longer decides what the patient does. At every session, the note answers three questions.

• Which process was worked on, and what shifted?
• Where is the patient with their values and with the actions they committed to?
• What has been agreed for next time, and what inner obstacle is expected?

For the general framework of a psychologist's notes (useful content, status, retention), see our article Psychologists' session notes: framework, content and template. Here we focus on what is specific to ACT.

How it differs from a standard CBT note

ACT is often grouped with the so-called third wave of cognitive and behavioural therapies, and many practitioners combine the two. But the note does not look at the same things. For the full CBT outline, see our CBT session note template. Here are only the differences.

• What you track
  • Standard CBT note. The reduction in symptoms and problem behaviours.
  • ACT note. Psychological flexibility and the actions taken for what matters.
• Thoughts
  • Standard CBT note. Their content, examined and challenged.
  • ACT note. Their effect on behaviour, and how much the patient believes them.
• Painful emotions
  • Standard CBT note. Their intensity, which you aim to reduce.
  • ACT note. What the patient does when they show up (fight, flee, let them be) and what that costs them.
• Tasks between sessions
  • Standard CBT note. A technical task (exposure, thought diary).
  • ACT note. A committed action linked to a value, with the expected inner obstacle.
• Measures
  • Standard CBT note. Symptom scales, anxiety before and after an exercise.
  • ACT note. Process questionnaires, believability of a thought, consistency between values and actions.

The six processes, and what to note for each

The ACT model describes six processes, often drawn on a hexagon, hence the nickname “hexaflex”. The names below are the most common. You will also come across variants, such as “being present” (the ACBS wording) for contact with the present moment, or “observing self” for self as context. Pick one set of terms and keep it in all your files.

• Acceptance
  • What you may observe. The patient lets an emotion or sensation come instead of fighting it. Or they avoid, change the subject, stop as soon as discomfort arrives.
  • Example wording. “Managed to stay 3 minutes with the lump in her throat without leaving the exercise.”
• Defusion
  • What you may observe. The patient sees a thought as a thought, not as a fact. According to the ACBS, the aim is to lower its believability, not its frequency.
  • Example wording. “Thought ‘I'm useless’, believability 90 at the start of the session, 60 after the exercise.”
• Contact with the present moment
  • What you may observe. The patient describes what they are experiencing here and now, without judging. Or they are pulled into the past or the future.
  • Example wording. “5-minute breathing exercise. Distracted by tomorrow's meeting, came back to the breath on his own three times.”
• Self as context
  • What you may observe. The patient observes their thoughts and emotions without being reduced to the story they tell about themselves.
  • Example wording. “Distinguishes ‘I am an anxious person’ from ‘I notice anxiety right now’.”
• Values
  • What you may observe. The patient names what matters to them, as a direction rather than a goal.
  • Example wording. “Family. Value in the patient's words, ‘being a mother who plays with her children’.”
• Committed action
  • What you may observe. The patient takes concrete steps towards their values, even with discomfort.
  • Example wording. “Called her sister as planned. Anxiety present, did not cut the call short.”

Each process has its flip side, what you see when the patient is stuck. The reference paper by Hayes and colleagues (2006) mainly describes two mechanisms. Cognitive fusion, when thoughts steer behaviour like orders. Experiential avoidance, when the person tries to change or escape their thoughts, emotions and sensations, even at the cost of what matters to them. Note these moments as much as the progress.

Do not fill in all six processes at every session. Note the one to three processes actually worked on, otherwise the note no longer shows what shifted.

Tracking values and committed actions from one session to the next

This is the part most specific to ACT. The ACBS describes values as chosen qualities of action, lived day by day and never achieved like an object. “Being a loyal friend” is a value. “Seeing Paul before the end of the month” is a goal. “Texting Paul on Tuesday evening” is a committed action.

For each value, note the patient's exact words and the life area (family, friendships, work, health…). For each committed action, note what, when, how often, and what is likely to show up. At the next session, note whether the action was done fully, partly or not at all, and what happened at that moment. An action not done is not a failure. It is information about what gets in the way.

The simplest approach is to keep, at the top of the file, a running log with one line per committed action.

• S3, 2 Sept.
  • Value (area). “Being a present father” (family)
  • Committed action. Watch 30 minutes of his son's match on Saturday.
  • Review at the next session. Done, stayed 40 minutes. Thought “I'll pay for it tomorrow” present.
• S3, 2 Sept.
  • Value (area). “Keeping my friends” (friendships)
  • Committed action. Call Karim before Thursday.
  • Review at the next session. Not done. Afraid Karim would ask why he no longer comes out.
• S4, 16 Sept.
  • Value (area). “Keeping my friends” (friendships)
  • Committed action. Write to Karim without waiting to feel ready.
  • Review at the next session. Partly done, message sent two days later.

Noting exercises and metaphors

ACT relies heavily on experiential exercises and metaphors. The French-language manual by Jean-Louis Monestès and Matthieu Villatte devotes a whole appendix to them. Among the best known are the passengers on the bus, the tug of war with a monster, and the compass, which presents values as a direction. In the note, three things are enough.

• What was offered. The name of the exercise and its length, or the metaphor.
• The patient's reaction. What they experienced, what was difficult.
• The words they picked up. When a patient says “the pain passenger always wants to drive”, write it down in quotation marks. These images become a shared vocabulary for later sessions.

Also note the metaphors that did not work. If you use the ACT Matrix, presented in French notably in the clinical guide by B. Schoendorff, J. Grand and M.-F. Bolduc, note what the patient placed in each area, in their own words.

Process questionnaires

Some questionnaires measure ACT processes rather than symptoms. They give a numerical reference point to compare over time. Do not copy the items into the note. Note the name of the tool, the version, the date, the score and which direction is better.

The AAQ-II

The Acceptance and Action Questionnaire II (Bond and colleagues, 2011) is the most widely used tool. It has 7 items, rated from 1 (“never true”) to 7 (“always true”). A higher score indicates more psychological inflexibility, that is, more experiential avoidance. A French version was validated by Monestès, Villatte, Mouras, Loas and Bond in 2009. The authors allow its use in research and with clients without prior permission, except for commercial use.

One limitation to know about. Tyndall and colleagues (2019) showed that AAQ-II scores are strongly linked to depression, anxiety and stress. It may therefore partly measure distress rather than avoidance. Read its change over time alongside your observations, never on its own.

Other tools

• The CompACT (Francis, Dawson and Golijani-Moghaddam, 2016) covers several processes in 23 items and three subscales (openness to experience, behavioural awareness, valued action).
• The Valued Living Questionnaire (Wilson and colleagues, 2010) goes through 10 life areas. The patient rates the importance of each from 1 to 10, then how consistent their actions over the past week have been with that area. The gap between the two can be followed over time.

The ACBS page on the Valued Living Questionnaire lists no French translation. For both tools, check that a validated version exists in your patient's language before using it, and state in the note which version you used.

A ready-to-use outline

It fits on one page. Delete the sections that are not useful for a given session.

1. Header. Date, session number, length, in person or video, goal of the therapy in one line.
2. Review of the committed action. Done, partly or not. What showed up and what the patient did with it.
3. What the patient brings. In their own words when they matter.
4. Processes worked on. One to three, with what shifted.
5. Exercises and metaphors. What was offered, the reaction, the words picked up.
6. Values mentioned. Life area and the patient's wording.
7. Measures. Questionnaire (name, version, score, direction), believability of a thought.
8. Practitioner's analysis. Hypotheses presented as such. Risk check if the question was asked.
9. Committed action agreed. What, when, how often, linked value, expected obstacle.
10. Next steps. Next session and what will be picked up.

Filled-in example (fictional patient)

Mr R., 41, an accountant, comes for chronic lower back pain of three years' standing and a gradual withdrawal from his social life. His GP handles the medical follow-up in parallel.

• Header. 30 September 2026, session 5, 50 minutes, in person. Goal of the therapy, getting back to the activities that matter to him despite the pain.
• Review of the committed action. Message to Karim sent two days after the planned date. Says he waited “to be sure I wouldn't look pathetic”. Karim suggests a coffee.
• What the patient brings. Pain worse this week (7 out of 10). Keeps saying “I'm a burden to everyone”.
• Processes worked on. Defusion on “I'm a burden”, believability 80 at the start, 50 at the end. Present moment, 5 minutes on the sensations in his back. Restless at first, then describes “it pulls on the left, it burns less when I breathe out”.
• Exercises and metaphors. Return to the passengers on the bus (session 3). Says spontaneously “the pain passenger always wants to drive”.
• Values mentioned. Family, “being a present father”. Friendships, “keeping my friends”.
• Measures. AAQ-II French version, 34 (39 at session 1, higher means more inflexibility). To be read with caution, this week's pain also weighs on it.
• Practitioner's analysis. Hypothesis, waiting to “feel ready” works as avoidance in the friendships area. Clear progress on the family side (actions done two weeks in a row). Asked about thoughts of death, says he has none.
• Committed action agreed. Have the coffee with Karim by 10 October, without waiting for the pain to ease. If the thought “I'll look pathetic” shows up, name it and go anyway. Linked value, “keeping my friends”.
• Next steps. Session on 14 October. Review the coffee with Karim. Introduce self as context around the story “I'm a burden”.

Common mistakes

• Writing a value as a goal. “Losing 5 kilos” is a goal. Ask the patient what that goal would allow them to live, and note their answer.
• Writing “task not done” and nothing else. What matters is what showed up at the moment of acting.
• Forgetting risk. The approach changes nothing about suicide risk assessment. The question asked, the answer and the decision go in the note.
• Writing values in a way that would embarrass the patient. In France, Belgium and Switzerland alike, the patient can in principle ask to read their file. Keep their words, without comments on their private life. See our article on patient access to their file.

How Delta works

Delta is an AI assistant for mental health professionals and allied health practitioners. During the session, Delta transcribes what is said, then prepares a session summary that you review and correct. You can also dictate your observations right after the session. Delta takes into account your specialty and your therapeutic approach. In ACT, the summary is therefore organised around what matters in this approach, and the patient file brings out the patient's progress across sessions, for example their committed actions and what came of them. Delta also drafts your assessment reports, letters and certificates.

Data is hosted in France, with a host certified for health data (HDS, the French certification for health data hosting). AI processing, transcription included, takes place on servers located in France. The patient's name and identifying information are pseudonymised before going through the AI, no audio file is kept, data is never used to train models, and it is encrypted in transit and at rest. On informing the patient, see our article on consent to AI note-taking. More outlines are in our clinical document templates, including the mindfulness-based therapy session note.

Frequently asked questions

Sources

• Association for Contextual Behavioral Science (ACBS), The Six Core Processes of ACT
• ACBS, Altenloh E., “ACT en quelques mots”, 2012
• ACBS, “The ACT Model, conceptually and self as lab”, 2021 World Conference (Hexaflex model)
• Hayes S.C. et al., “Acceptance and Commitment Therapy: Model, processes and outcomes”, Behaviour Research and Therapy, 2006, 44(1), 1-25
• ACBS, The 7-item Acceptance and Action Questionnaire II (AAQ-II), Bond et al., Behavior Therapy, 2011, 42, 676-688
• Goldsmiths, University of London, Bond F.W. et al., “Preliminary psychometric properties of the Acceptance and Action Questionnaire II”, 2011
• University of Coimbra, CINEICC, AAQ-II information sheet
• ACBS, Acceptance and Action Questionnaire, conditions of use
• ACBS, AAQ-II in French (Monestès J.-L. et al., Revue européenne de psychologie appliquée, 2009, 59, 301-308)
• Tyndall I. et al., “The Acceptance and Action Questionnaire II (AAQ-II) as a measure of experiential avoidance: Concerns over discriminant validity”, Journal of Contextual Behavioral Science, 2019, 12, 278-284
• University of Coimbra, CINEICC, CompACT information sheet
• ACBS, Valued Living Questionnaire (Wilson et al., The Psychological Record, 2010, 60, 249-272)
• The Valued Living Questionnaire, reprinted with permission from the authors
• Monestès J.-L., Villatte M., La thérapie d'acceptation et d'engagement, ACT, Elsevier Masson, 2011
• Schoendorff B., Grand J., Bolduc M.-F., La thérapie d'acceptation et d'engagement, guide clinique, De Boeck, 2011
• British Psychological Society, Laidler V., “Eye on Fiction: Making room for values and emotions”, The Psychologist, 2017
• Society of Clinical Psychology (APA, Division 12), Acceptance and Commitment Therapy for Chronic Pain