ACT-GRO FRAMEWORK an Integrated Conceptual and Practical Framework

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International Journal of Adventure Therapy | Volume 1, 2023 (in press)
The ACT-GRO Framework – an integrated

conceptual and practical framework
Abstract
This paper proposes a framework integrating three therapeutic modes, namely
Acceptance and Commitment Therapy (ACT), Outdoor Therapy and Group Therapy. We
describe the ACT-GRO (ACT - Group Outdoor) Framework, its components, rationale
behind the proposed Framework and explain how each component enhances the other
and can be viewed as a system of systems-a term borrowed from engineering – requiring
each system to be autonomous, connected, and diverse, with a common purpose and a
commitment to a greater outcome. In the second part, we describe how the three
therapeutic modes working in an integrative way meet Baldwin’s criteria of a system of
systems. Finally, we discuss challenges and call for directions for future research.
Keywords
Wilderness adventure therapy; group therapy; Acceptance and commitment therapy

(ACT), Cognitive behaviour therapy; Outdoor Therapy
www.journal-adventure-therapy.com International Journal of Adventure Therapy

ISSN 2700-7375, Volume 1, 2023 Internationale Zeitschrift für Erlebnistherapie
Adam Leighton, Dotan Haim, Arnon Rolnick, Miriam Ben Hirsch-Gornemann 2
1 Background
Integrating multiple therapeutic modalities, a concept that has been gaining popularity in
psychotherapy, is seen as a way to provide a more client-centred approach and improve
treatment efficacy and efficiency (Castonguay et al., 2015). This approach aims to integrate
and harmonize different methodologies, techniques, and modalities (such as individual,
group, and family therapy) that have been supported by empirical evidence, in a synergistic
manner, to achieve an outcome that is greater than the sum of its components and most
suited to specific clients’ needs
Castonguay et al. (2015) described an approach to integrating therapies they called

"assimilative integration", which allows "remaining anchored in a primary theoretical
orientation while thoughtfully integrating techniques and principles from other
orientations" (p. 366). The ACT-GRO framework outlined in this paper follows this
assimilative integration approach. In addition to outlining the integration of various
techniques and principles, we also explore how they can mutually enhance one another.
Outdoor Therapy (OT) in its various forms e.g. wilderness adventure therapy, wilderness
therapy, adventure therapy, nature based therapy and eco-therapy) is an effective and
unique form of psychotherapy, with growing evidence supporting its efficacy (Bowen &
Neill, 2013; Corazon et al., 2019). While commonly conducted in a group format, OT should
be considered as a therapeutic modality in its own right as it can also be carried out in
individual format. When implementing OT in a group setting, it is crucial for the practitioner
to be aware of both OT theory and techniques, as well as the chosen group therapy
approach, such as the Interpersonal Model of Group Psychotherapy (Yalom and Leszcz
2008) or Systems Centred Therapy (SCT) (Agazarian, 2018). We suggest that integrating
both group therapy techniques and principles of OT throughout the therapeutic program
ensures that the therapy is congruent and aims to optimize the outcome by maximizing
the synergistic effects of both approaches. This is in contrast to simply carrying out OT in a
group without fully utilising the benefits of GT.
Acceptance and Commitment Therapy (ACT) is an increasingly popular evidenced based
approach stemming from Cognitive Behavioral Therapy. ACT aims to change behaviours
and attitudes towards one’s internal experiences (emotions, thoughts and sensations) in
order live a meaningful life (Hayes et al., 2003). ACT emphasizes developing a willingness
to accept unpleasant internal experiences as a flexible alternative to controlling them thus
reducing the internal struggle and suffering. Core processes in ACT include the ability to be
present in the moment, to act towards motivating values, and to choose to behave in
accordance with those values while acknowledging the presence of unpleasant
experiences. We will later describe in more detail the six core ACT processes.
The idea of using ACT with Adventure therapy is relatively new, first described by Tracey et
al. (2018) and Truong et al. (2018) as a method to improve psychological well-being for
children as risk. We propose that (a) ACT can be integrated with OT for therapeutic goals
for a wide variety of patients; (b) when applied in a group context, the therapist needs to
relate to ACT, OT and group mechanisms of change independently and interpretively,
International Journal of Adventure Therapy
Internationale Zeitschrift für Erlebnistherapie
ISSN 2700-7375, Volume 1, 2023
© 2022 ZIEL GmbH, Augsburg
3 The ACT-GRO Framework
viewing them as a system of systems; and; (c) we propose a structure for sessions and for
treatment programmes.
In this paper, we present a framework consisting of three systems: ACT, OT and group
therapy. We provide an overview of the rationale for the selection of these systems, and
the framework is conceptualized as a system of systems based on the criteria outlined by
Baldwin and Sauser (2009). We will further explore how elements within each of the
systems can complement and enhance elements from the other systems, illustrating the
added value of an assimilative integration approach. Finally, we will discuss patient
compatibility, implications for training, research, and application of this model in clinical
settings.
2 Approach
The ACT-GRO Framework is based on the authors’ belief that integrating three existing
modalities may lead to improved outcomes in terms of efficiency, mental health
improvement, and reduced dropout rates. Rather than introducing a new modality, the
framework offers a systematic approach for examining the interactions between the three
modalities. The framework provides a comprehensive understanding of the relationships
between the components, as outlined in Jabareen’s (2009) definition of a conceptual
framework. Conceptual frameworks are beneficial in situations where a singular theory is
inadequate for fully comprehending or addressing a particular phenomenon. Their value
lies in their ability to offer a comprehensive understanding of the overall context and the
connections between the various components of the framework.
In terms of systems theory (an interdisciplinary study of systems theory in general, not to
be confused with Systems Centred Therapy, a group therapy approach), the ACT-GRO
Framework can be described as a system of systems, in which the three modalities operate
autonomously but with a shared goal. Baldwin (2009) identified six criteria for a system of
systems: autonomy, belonging, connectivity, diversity, and emergence. The three
modalities in the ACT-GRO Framework meet these criteria as they are autonomous
therapeutic approaches that operate towards the common goal of improving participants'
psychological wellbeing. Additionally, the diversity of the modalities is presented as a key
aspect of the framework's effectiveness. Further research is needed to fully explore the
emergence criteria and their potential impact on the framework's effectiveness.
Initially, we provide a brief overview of the key elements of the three systems and the
rationale for selecting their inclusion in the ACT-GRO Framework. We will then discuss how
the systems enhance each other, leading to an increased overall efficacy of the therapeutic
outcome.

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3 ACT-GRO Framework Components (Systems)

3.1. Acceptance and Commitment Therapy (ACT)
3.1.1. Inclusion of ACT in the ACT-GRO Framework
The criteria for selecting the appropriate system of psychotherapy for use in the ACT-GRO
Framework were based on evidence for its effectiveness in group format, structured
approach, transdiagnostic nature, and efficacy. ACT has been demonstrated to be effective
in group format with a wide range of clinical conditions, ages and backgrounds (Eilenberg
et al., 2016; Khaneghaee et al., 2019; Luciano et al., 2014; Pourfaraj, 2011; Rajabi &
Yazdkhasti, 2014; Smith et al., 2020). A structured session approach, as described by Ona
(2020), lends itself to a group format. Each session can be dedicated to a specific module,
such as dealing with emotions, allowing therapists/facilitators to plan activities and
psychoeducation subjects according to the protocol. Although this structure is extremely
helpful, flexibility is also important to allow therapists/facilitators to respond to the needs
of the group in the present moment.
Groups are never truly homogeneous (Söchting, 2014) even when symptomatically similar.
Two patients diagnosed with social anxiety may have extremely different underlying fears,
not to mention the prevalence of comorbidities in many cases. We, therefore, prefer a
therapeutic approach that can relate to the different conditions in the group. ACT is a
transdiagnostic approach, which is particularly useful for addressing the diverse needs of
group members.
3.1.2. Brief description of ACT
The six core processes described in ACT are acceptance, contact with the present
moment, defusion, self-as-context, values and committed action. The internalization of
these processes (described below) allows what Hayes refers to as psychological flexibility,
the ability to choose a behavioural response to internal and external triggers as opposed
to following an automatic response. Psychological flexibility involves being open to and
fully present with our thoughts and feelings, while at the same time being able to take
committed action in line with our values and goals.
When we cultivate psychological flexibility, we become more resilient to stress and able to
handle difficult emotions more effectively. We are able to choose our actions based on our
values and what matters to us, rather than being controlled by our thoughts and emotions.
This, in turn, can lead to a greater sense of purpose, meaning, and fulfilment in life.
3.1.2.1. The Six Core Processes

Acceptance is the willingness to allow the presence of unpleasant thoughts,
feelings, sensations and events of the human experience. Acceptance is generally
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a more adaptive approach than struggling to get rid of unpleasant feelings or

discomfort. ACT posits that the struggle itself is frequently the cause of much of
our suffering.
Contact the Present Moment - “being in the here and now”. This process refers to
the ability to focus on what is happening to you and/or your environment at
present. The ability to shift attention with intent to experience sensations and
emotions, regardless of if they are pleasant or not. The processes of contacting the
present moment and acceptance are closely related to the concept of mindfulness.
Defusion - the ability to distance ourselves from our thoughts (words or images in
consciousness), to observe them without become submersed in their content.
Self as context refers to the "observing self"(Harris, 2008), a non-judgemental state

of self-awareness. It describes the process that allows one to step back and
observe ‘what is happening inside’. Bernstein et al., (2015) describe similar
processes as Metacognitive Processes of Decentering and examine the prevalence
of similar processes in various approaches.
Values, or as the authors frequently refer to as motivating values, relate to ones

chosen personal values. Values describe how one would like to live their life and
can motivate adaptive behaviours even when experiencing extremely
uncomfortable thoughts, emotions or sensations.
Committed action refers to behaving according to one’s values allowing to create a

satisfying, meaningful life.
In the following sections will provide a brief overview of the two additional systems
included in the ACT-GRO framework, namely OT and GT.
3.2. Outdoor Therapy
The ACT-GRO framework was developed with OT (outdoor therapy) as its foundation.
Therefore, we will not describe the reasons for the incorporation of OT in the framework.
Instead, we will provide a concise OT as a system and identify its constituent
components. This approach will facilitate our assessment and integration of OT into the
ACT-GRO framework, which is itself a system of systems.
3.2.1. OT through a systems theory lens
The analysis conducted by Taylor et al. (2010) investigated adventure therapy using the
integrative systems theory perspective. This theory, akin to the 'system of systems'
concept, elucidates the interrelationships between various systems. While the authors

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focused on adventure therapy, their study accentuated the crucial role of nature within the
system. Hence, we consider their findings pertinent to our current paper.
In the above paper the authors identified the interaction of various elements within the
self-system (the participants) including a person’s status and identity, physicality, thoughts,
feelings, perception and novel experiences interact through human behaviour (the actions)
with other systems (e.g. other people, the environment). Examples of
behaviours/interactions may include observation, experiencing, resistance and conversely,
learning. WE SHALL EXAMINE THESE INTEREACTION IN SECTION 4
3.2.2. Brief description of Outdoor Therapy (OT)
The family of outdoor therapies (e.g., Adventure Therapy, Wilderness Therapy, Ecotherapy.
Nature-based therapy and Wilderness Adventure Therapy) focus on learning through
interaction with physical novel situations frequently in the context of a group. A key part
of the learning is through the reflective process, “learning by doing with reflection” (Priest
& Gass, 2018, p. 29).
Gabrielsen et al. (2018) described six key elements of Wilderness therapy (see Table 1). We
will later examine the interaction of these elements, with elements from the other systems
(ACT & Group Therapy). This interaction between systems forms the foundation of the
framework model. For instance, we shall explicate in next section the how the component
of 'Natural consequences,' as delineated in the table below, interacts with 'present
awareness,' a pivotal element (process) previously described in ACT.
Table 1: Key elements of Wilderness Therapy (based on Gabrielsen et al., 2018)
Element Description
1. Experiential learning "Learning by doing" through group outdoor travel and activities. Tasks such as
methods food preparation and river crossing are used as opportunities for social learning
and assessment. Emphasis is placed on the the engagement of clients and
therapists in the physical and social dynamics of the environment.
2. Integration of Therapists have the flexibility to select and implement individual therapy, group
therapeutic practice therapy, psycho-education, or social group learning. The daily travel and living
into group travel and demands flexibility in roles and responsibilities for all, with therapy taking place
outdoor living beyond traditional 60-minute sessions, particularly on multi-day wilderness
trips. The close proximity of therapists and clients in these settings accelerates
the therapist's ability to assess and work with clients in real-life situations.
3. Connection to Socio-ecological factors such as place-based knowledge and land-based

place practices are considered. Factors such as clients' cultural and social
backgrounds, psychological states, and diagnoses are taken into account when
choosing the trip location, intensity, and natural and cultural heritage features.
Clients are also encouraged to bring their own ecological selves, including
heritage, knowledge, skills, and experiences in the outdoors, into the new
environment to learn about the place and its history, flora and fauna, spiritual or

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sacred spaces, terrain features and geography. The sense of self is closely
connected to nature, and this connection is often underutilized in therapy.
4. Reflection and the Being in remote natural spaces allows clients to reflect and gain insight into their
generation of lives and experiences. Nature provides opportunities for clients to find
metaphors connections and parallels between their experiences and the natural world,
which can become central to their personal narrative. Guided alone-time and
periods of inactivity also facilitate introspection and new ways of understanding.
5. Challenge Adventure activities tailored to clients' abilities and therapeutic and social goals
are included. Staff provide support and mentorship to ensure appropriate levels
of challenge and risk while balancing perceived risk and task burden. The
unknown outcomes of these activities provide opportunities for disruptive
learning, such as self-discovery of strengths and abilities.
6. Natural Client actions and choices have clear and unambiguous feedback. Weather
consequences changes, varying terrain, individual and group decisions etc. all carry the
potential for unknown outcomes and many provide optimal learning moments.
(e.g. client is shown how to load their backpack including keeping rain gear
accessible. When raining, the client is refusing to wear rain gear due to its
inconvenient location in the bottom of their pack. Client gets wet and cold,
becoming weak and frustrated. Process between therapist and client in
unpacking, changing to dry clothes, and, in putting on rain gear is ripe for
opportunities to discuss goal-setting, self-care, organizational skills, and the
impact one’s decisions have on others etc.)
Experiential activities and approaches can take on a variety of formats and durations, from
long-term programmes in the desert to brief indoor interventions during therapy sessions.
The integration of therapeutic practices into group travel and outdoor living is more
profound in longer duration programs such as multiday journeys. The benefits of
experiential elements should not be limited to traditional outdoor therapy programs but
can, and we suggest should, be incorporated into all therapists' toolkits. We propose
therapeutic sessions should aim to include physical, emotional, cognitive, and social
experiential elements.
3.3. Group Therapy
Group therapy is a well-established therapeutic modality that offers an efficient and cost-
effective approach (Toseland & Siporin, 2015). However, further research is needed to
compare the efficiency of group treatment to individual treatment.

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Traditionally, group therapy is conducted by one or two therapists, known as leaders or

facilitators, who work with a group of people over a series of sessions. The format of the
sessions depends on the group therapy approach, which can be broadly categorized as
short-term or long-term groups. Short-term groups typically last for a few weeks or
months, while long-term groups may continue for several years. Groups typically consist of
8-12 participants.
3.3.1. Inclusion of the Interpersonal Group Therapy approach in the ACT-

GRO Framework.
Group therapy approaches differ in underlying theory, conceptualisation of group

processes, and techniques. Prevalent approaches include Psychodynamic,
Psychoanalytical, Psychodrama, Systems Centred and Interpersonal group therapy. We
have selected the Interpersonal Group Therapy approach as described by Yalom and Leszcz
(2008) to include in the ACT-GRO Framework. We posit that the the Interpersonal Group
Therapy approach complement and enhance the systems of OT and ACT.
One of the benefits of the IGT approach is that it allows for the breakdown of complex
issues by focusing on their individual components (primarily the 11 therapeutic factors
listed under 3.3.2.), which in turn helps in understanding the overall phenomenon through
its basic processes. (Yalom & Leszcz, 2008, p. 22). Furthermore, IGT’s emphasis on the
importance of the present moment is congruent with both ACT’s approach, and the
experiential elements of OT.
3.3.2. Interpersonal Group Therapy (IGT)
Interpersonal Group Therapy (IGT) focuses on both the objectives and techniques that
involve interactions between individuals (Brabender et al., 2004). The main objective of IGT
is to help individuals improve their ability to form positive relationships with othersby
addressing the way group members interact with each other during the therapy sessions.
IGT is one of the three main approaches used in group therapy and has led to a wealth of
research on the factors that contribute to positive change within a group.
Yalom and Leszcz (2008) listed 11 therapeutic factors that they view as central in group
therapy. Awareness of these factors can help the therapist fully utilise the potential that
group therapy can offer. The factors are (1) Instillation of hope; (2) Universality; (3)
Imparting information; (4) Altruism; (5) The corrective recapitulation of the primary family
group; (6) Development of socializing techniques; (7) Imitative behaviour; (8) Interpersonal
learning; (9) Group cohesiveness; (10) Catharsis; and (11) Existential factors. For a full
description of these factors, the reader is recommended to refer to their book.
An essential aspect of group therapy is the therapeutic value of relationships between

participants and themselves (cohesion), participants and the therapists (group alliance)
and between participants / the group itself as an entity.

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It is important to underscore that the act of conducting ACT or OT in a group setting does
not equate to the integration of GT with these therapies. While there may be heightened
efficiency in administering ACT and/or OT in a group format, the mere presence of several
individuals does not constitute group therapy unless group therapeutic elements are
intentionally employed. Therapists utilising the group format should "tap the unique
benefits inherent in the group arena” (Yalom & Leszcz, 2008, p. 582) and not just use
groups to increase the efficiency of delivering ACT / OT to individual clients.
4.1. Integrating the three systems in the ACT-GRO Framework
To further understand how the ACT-GRO Framework operates as a system of systems, we

will examine the interactions between its three components (systems) using both a top-
down approach and by providing real-world examples of how they interact. Our contention
is that the interactions between the components typically involve the transmission of
information, either through the redirection of attention, experiential engagement,
observation, or dialogue. These interactions are facilitated by either the group therapist or
participants. The primary aim of such interactions between the elements is to heighten
participants' learning, with the interaction among the elements being crucial to this end,
rather than the participants or group focusing solely on a single element in isolation.
As an illustration, the activity of mountain climbing can be regarded as a challenge, which

is an element from AT, while present awareness constitutes an element from ACT. When a
therapist suggests to a participant to direct their attention to present-moment experiences
whilst mountain climbing, an interaction between challenge and present awareness is
established. Such an interaction may involve a redirection of attention, experiential
engagement, and observation. This example exemplifies how such an interaction
facilitates the participant's development of present awareness skills, leading to a more
favourable outcome compared to the solitary practice of present awareness in a clinical
setting or the mere physical act of mountain climbing.
Figure 1 provides a visual representation of how these components interact with each
other within the framework.

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Figure 1. Interaction of systems in the framework of the ACT-GRO Framework
Outdoor therapy
•Challenge
•Experien�al learning methods
•Connec�on to nature
•Integra�on of therapeu�c prac�ce
•Natural consequences
into group travel and outdoor
living •Physical wellbeing
•Connec�on to place
Interac�ons between
elements of each system
via shi� of a�en�on,
observa�on and/or dialogue
ACT Group therapy •Development of socializing

techniques
•Acceptance •Self as Context •Ins�lla�on of hope •Imita�ve behaviour
•Present awareness •Values •Universality •Interpersonal learning
•Defusion •Commi�ed Ac�on •Impar�ng informa�on •Group cohesiveness
•Altruism •Catharsis
•Existen�al factors
The interplay between various therapeutic group factors and elements of Outdoor
Therapy (OT) and Acceptance and Commitment Therapy (ACT) can enhance each other, as
shown in Table 2. This table provides insight into how these different modalities relate to
and support each other within the ACT-GRO Framework. Understanding these
relationships can be helpful in optimizing the effectiveness of these therapies.
A similar table could be constructed to show how the ACT-GRO Framework can be viewed
from the perspective of Outdoor Therapy (OT) or Acceptance and Commitment Therapy
(ACT). This table would demonstrate, for example, how the use of outdoor activities in OT
can provide a unique context for practicing the skills and strategies learned in ACT.
Table 2. Key Therapeutic factors in group therapy and its associations with components of OT
and ACT
Group Therapy Outdoor therapy ACT
Instillation of hope Playfulness, optimal arousal flow, Values, committed action
competence through experience,
biophilia, competence motivation
Altruism Experiential reciprocity Values (depending on participants
values), committed action, self as context
Cohesion Experiential reciprocity Cohesion enhances openness, safety and
experiential group efficacy commitment therefore supporting
present awareness, acceptance, and
committed action
Universality Shared experiences and Examining processes vs specific
challenges. Existential elements. symptoms increases universality.
Universality can enhance acceptance.
Interpersonal learning Group activities and tasks requiring Examining processes vs specific
complex interpersonal symptoms increases ability to learn from
interactions, others. Interpersonal learning can
Experiential learning

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support acceptance, defusion, self as

context, values, committed action.
Imparting information Skills development, Psychoeducation
Environmental education,
experiential learning, problem-
solving
Catharsis Flow, nature environment, self- Present awareness can enhance cathartic
efficacy, experiential elements moments.
Identification/ Group activities and tasks requiring Imitative behaviour can assist committed
Imitative behaviour complex interpersonal action.
interactions.
The corrective Not relevant To a limited degree - therapeutic
recapitulation of the relationship
family group
Self-Understanding Activity reflection (individual), All act processes support self-awareness.
isomorphic framing
Existential factors Nature as an existential factor, Acceptance, present awareness.
perceived risk
Examining a specific example, we can investigate how the therapeutic factor of

"Universality" (shared experiences and common struggles) operates within different
systems of group therapy. In traditional group therapy, universality is commonly achieved
through discussion of shared internal (physical, emotional, and cognitive experiences ) and
external events. However, when group therapy is conducted in an outdoor setting, the
shared experiences expand to include physical, emotional, and cognitive experiences,
often involving facilitators as well. In group ACT, universality is deepened as participants
not only discuss shared internal experiences but also gain insight into underlying universal
processes, such as avoidant behaviours.
To illustrate, we consider a group cooking a meal outdoors when it unexpectedly starts to

rain (natural consequences - an element of outdoor therapy, as seen in Table 1). The group
quickly gathers up all their supplies and finds shelter from the rain. While waiting for the
conditions to improve, an argument breaks out. Clearly, the physical experience is shared
by all. During the subsequent reflection, group members become aware of the frustration
(ACT process - present awareness) that many of them experienced and realized that anger
was related to avoidance (the opposite of acceptance) of uncomfortable emotions and
sensations. Understanding that many of the group members were undergoing similar
internal experiences, helped them develop willingness to notice and accept their own
emotions and sensations (ACT process- acceptance). The group cohesion was central in
allowing our imaginary group to openly reflect and share their frustration and anger.
Through this example, we can see how the therapeutic group factor universality as well as
interpersonal learning and existential factors interact with elements of both ACT and
outdoor therapy. It is noteworthy that the existential factors are common to both group
therapy and outdoor therapy, as demonstrated in this example. Figure 2 illustrates the
different elements involved in the above example.

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Figure 2. Examining interaction of systems - rain whilst cooking outdoors example
Outdoor therapy •Challenge

•Connec�on to nature
•Experien�al learning methods
•Natural consequences
•Integra�on of therapeu�c prac�ce
into group travel and outdoor living
– par�cularly shared experience.
ACT Group therapy

•Acceptance •Universality
•Present awareness •Group cohesiveness
•Existen�al factors
•interpersonal learning
To further illustrate, we consider a group participating in a challenging activity, such as

lifting each participant over a rope while following certain guidelines (e.g., Spider Web -
Teampedia, n.d.). The physical intimacy required during the activity may push some
members out of their comfort zones. After the group successfully completes the task,
during the reflection session, a participant with severe social anxiety may express how they
noticed the presence of unpleasant emotions and thoughts (ACT - present awareness),
particularly thoughts such as "I will certainly make a fool of myself and let the group down".
He then shares that by recognizing these catastrophic thoughts using skills (ACT - defusion)
learned through the program and focusing on his personal values helped him complete the
task, even though the thoughts were still present. The participant may also note the strong
feelings of affection they have for the group, and how that also helped them.
In this example, we can see how the challenge element from the outdoor activity system
interacts with various therapeutic factors of group therapy, specifically, cohesion, instilling
hope (the success in overcoming challenges) and self-understanding. The challenge element
directly interacted with key processes of ACT including present awareness (of inner
experiences), defusion (from thoughts), values and committed action.
Finally, we explore how the different systems interact by examining the example of
wilderness solo experiences, a potentially powerful outdoor activity commonly included in
outdoor programs (Naor & Mayseless, 2020). This activity involves participants spending a
certain period of time in a secluded natural location on their own. Participants are
encouraged to pay attention to their physical sensations, including those that may be
uncomfortable. They are also encouraged to engage their senses through play and
experimentation, such as feeling the ground with their hands, smelling different scents,
and listening to all sounds, even if they elicit a degree of fear. This activity is designed to
increase awareness and willingness to experience unpleasant emotions and physical
sensations, present awareness, and acceptance, two key ACT processes. The experiential
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learning enhances this learning. Many participants find this activity challenging (key OT
element), and successful participation can boost their confidence. These activities are
typically programmed after the group has developed cohesion, as this is an important
supporting factor that helps participants push their limits.
The three above examples demonstrate how the three modalities clearly answer to the
criteria of connectivity and emergence of a system of systems as Baldwin (2009) required.
4.2. Programme Structure
The ACT-GRO Framework is a structured program that includes 10-12 sessions of

approximately 90-120 minutes each. These sessions consist of a combination of
experiential activities, psychoeducation, reflection, and group discussions. The framework
is flexible and can also be adapted to include multi-day trips or a combination of shorter
sessions and outdoor activities.
The programme is divided into three stages: Building a performing group, Core Sessions, and
Assimilation and Closure. The initial stage, Building a performing group, places a strong
emphasis on building cohesion among group members, which has been shown to be a key
factor in the success of group therapy (Burlingame et al., 2011).
The Core Sessions are based on the core processes of ACT and incorporate outdoor
experiential activities to promote active learning and application of ACT processes. The
program concludes with Assimilation and Closure sessions focused on integrating and
assimilating the learned ACT and social skills and focusing on committed action, followed
by a closure and follow-up meeting scheduled 30 days after the summary session. This
stage includes elements similar to those described in the literature as “termination”
(Yalom & Leszcz, 2008, p. 469) or “adjourning” (Tuckman & Jensen, 1977). The last
session is preceded by a longer period of time for participants to practice the skills and
strategies learned on their own. This allows the facilitator/therapist to evaluate each
participant’s progress and determine if additional support is necessary after the final
session. Table 3 delineates the focus of each system across the stages of the programme.

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To illustrate, during the building a performing group stage, the focus of the OT activities
will be supporting group cohesion.
Table 3. Main components (systems) of the ACT-GRO Framework and Programme rationale
Stage in programme
Building a performing
Core modules Assimila�on and closure
group
Outdoor Suppor�ng group Experiences allow Suppor�ng skills

Therapeu�c system
cohesion discovery, prac�cing assimila�on & group

& assimila�on closure
Group Focus on group Enhances outdoor Focus on group

development and ACT closure
Focus on ACT - self Focus on all skills&

Acceptance & Focus on values /
mo�va�onal learning and learning par�cularly
Commitment enhancement skills commi�ed ac�on
4.2.1. Core sessions
The core sessions of the ACT-GRO Framework program incorporate three distinct learning
methods: discovery, psychoeducation, and skills practice and assimilation. These methods
support the knowledge goals of each module in the program. The discovery method
utilizes experiential learning through group activities and reflection to facilitate
psychoeducation and skill-learning. For example, a group activity where participants wear
blindfolds and build a rectangular shape using a rope, followed by reflection on the
thoughts and behaviours experienced during the activity. Psychoeducation includes
learning skills, gaining knowledge and self-learning, often through structured didactic
learning and internal reflection. Psychoeducation for the above example could include a
brief explanation of brain structure, different types of thinking and discussing “emotion-
driven behaviors to values-based behaviors” (Ona, 2020, p. 55). Skills practice typically
takes place in smaller groups, allowing participants to try out the skills and guide their
partners, boosting feelings of self-efficacy and altruism. Similar to CBT therapy sessions,
between-session assignments are an integral part of the process. Assignments can also
be set in small groups, with the agreed assignments shared in the larger group,
contributing to commitment. Figure 4 illustrates an example of a session structure,
highlighting the key modality in action and the different learning methods used.
Figure 3. Sample session structure with breakdown of different elements from the 3 modalities
and through the perspective of discovery, psychoeducation and practice & assimilation.

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Group Outdoor ACT Psycho - Prac�ce &

Discovery
educa�on assimila�on
X X Icebreakers / Check-in round (Duﬀy,2008)
Experien�al core exercise (the order can be

X X X switched with psycho-educa�on) X X
Psycho-educa�on (conceptualiza�on, learning
X X tools/skills) X
X X X Reﬂec�on
X X X
Prac�ce learnt tools/skills in small groups
X X (usually in groups of three) X X
X X Sharing
X X
X Se�ng assignments for work between sessions
X
X X Summary
X
We can see in figure 3 that ‘experiential core exercise’ for example is strongly related to all
modalities. It includes both discovery and practice & assimilation as the activity can be used
to elicit the main planned subject of the session (e.g. emotional awareness) and at the
same time may include the practice of techniques previously learned e.g. cognitive
flexibility.
4.2.2. The reflection process
All experiential learning models place tremendous value on the reflection process, as
Priest and Gass (2018, p.29) described,: “Indeed, reflection on experience is a precursor to
learning, for without reflection, learning loses much of its value”.
This is particularly true in the ACT-GRO as the integration of the three systems is most fully
realized during the reflection process..
In the ACT-GRO Framework, we distinguish between two types of reflection; group-

oriented and individual-centric. Both types follow Kolb's (Kolb, 2015, p. 51) model of
experiential learning cycle (experiencing, reflecting, conceptualisation, experimentation),
but the focus of individual-centric reflection is on each participant's internal experiences.
Using Borton’s (Borton, 1970) reflective questions of "What?", "So What?", and "Now
What?" in an individual-centric reflection, the "What" pertains to one's internal experiences,
the "So What" involves the participant's reaction to those experiences, and the "Now What"
focuses on exploring flexible options for dealing with unpleasant internal experiences.

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5 Discussion
5.1. Research needs in integrative psychotherapy
The effectiveness of integrative psychotherapy approaches, such as the ACT-GRO

Framework, has not been extensively studied. Castonguay et al. (2015) suggested research
in integrative psychotherapy approaches should focus on comparing the effectiveness of
the integrative approach to individual approaches, identifying common and unique factors
that contribute to change, determining who is most likely to respond to the integration,
and identifying factors that can lead to, prevent, or repair negative effects. Although the
ACT-GRO Framework is a combination of well-researched individual systems, research is
required to demonstrate the added value of the integration. To increase adoption of the
ACT-GRO Framework, further research in these areas is required. Additionally, challenges
related to training must also be considered in research and evaluation of the ACT-GRO
Framework.
5.2. Participant compatibility
Participant/Patient compatibility is a crucial consideration when examining the different

therapeutic systems (ACT, OT, and GT). Each system has its own unique features that may
not be appropriate for all patients.
There is a lack of extensive literature that offers precise criteria for evaluating whether a
patient is a good fit for OT. Indeed, the ability to forecast psychotherapy in general
suitability is extremely challenging. The importance and complexity of informed consent in
OT is suggested as part of the solution along with clear dialogue with potential candidates
regarding expectations with regards to outcomes and interaction with nature (Cooley et
al., 2020; Harper & Dobud, 2021, p. 11).
ACT has been successfully applied in a variety of clinical and non-clinical settings, but
further research is needed to explore potential cross-cultural differences (Akbari et al.,
2022; Ona, 2020, p. 17).
Woods and Melnick (1979) identified various criteria for selecting participants for group
therapy, including interpersonal skills, treatment motivation, positive expectations,
psychological distress, interpersonal problems, commitment to behavioral change,
susceptibility to group influence, and willingness to help others.
Research is required to determine if and how the integration as suggested in the ACT-ACT-
GRO framework impacts the approach for specific patients.
5.3. Opportunities and Challenges for Future Training
Throughout the paper, the reader may have noticed the dual or perhaps ambiguous use
of the term facilitator/therapist. This reflects the complexity of the facilitator's role and
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the requisite knowledge stemming from the tripartite nature of facilitation, which
demands comprehension of all three systems. We posit that the most formidable
obstacle to the widespread adoption of the AGRO ACT-GRO Framework is the
multifaceted nature of facilitation. Castonguay et al. (2015) asked
Should graduate students be trained from the beginning as integrative therapists,
or should they first master competencies in some orientations before they learn
how to integrate them? Can or should integration be achieved within the
framework of one theoretical orientation?".? (p. 376)
In our training programme, we have adopted the first option, namely we are training
integrative group facilitators. However, whether this approach is ideal needs to be
examined in order to provide some evidence of standardization in training, if we want to
obtain the best benefits of the intervention, both for outcome evaluation and research
purposes.
Finally, in terms of ACT-GRO Framework certification, we align with the stance proposed
by Hayes (2013), in which we view the framework as ‘open-source’. We believe that the
model should be continuously developed and improved. Hayes and his team, while
describing their approach to Scientific System Development, proposed the establishment
of "an open, diverse, and non-hierarchical development community” (Hayes et al., 2013
p.192). Certification, by its nature, is hierarchical and moderated, which can hinder
dynamic growth. Therefore, we argue that instead of supporting ACT-GRO Framework
certification, a list of suggested skills and knowledge required for ACT-GRO Framework
facilitators should be provided. This will be the subject for a future publication.
5.4. Application in ‘traditional’ clinical setting - getting off our seats
Throughout this article, the authors have discussed the application of the ACT-GRO
Framework in outdoor group settings. We propose that elements of the model can also be
applied in many if not all other therapy frameworks. Most therapeutic modalities have clear
learning goals for patients: learning new habits that promote wellbeing, psychoeducation
and self-discovery. Experiential learning, which has been shown to be highly effective, can
enhance the therapeutic process by incorporating physical, cognitive, social, and
emotional experiences. Therapeutic modalities that utilize in-vivo exposure already include
physical and social experiences. Therapists can also engage the body through playful
activities, such as stretching exercises, singing, or sharing a snack!
Picture interpretation techniques are frequently used to help express internal experiences
which the patient struggles to express. Instead of limiting ourselves to a static 2-
dimensional image, we could sit in a park or even in a café, observing the environment as
a dynamic thematic metaphor and sharing thoughts, emotions and sensations that may
appear.

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A central tenet of Gestalt therapy (for further information see

https://www.ganz.org.au/gestalt-therapy/ (Gestalt Therapy, n.d.)) is the wholeness of the
patient in the therapeutic relationship, which includes behavioural, physiological, affective,
cognitive and spiritual aspects (Clarkson & Cavicchia, 2013). Therefore, it is suggested that
therapists should not limit their work to the boundaries of the clinic but incorporate
activities that involve the body and the environment. We are not suggesting that every
therapist must retrain as an outdoor specialist, however this can be seen as a call to literally
get off our seats in therapy.
6 Conclusion
The ACT-GRO framework is a combination of three therapeutic modalities (ACT, OT, and
Interpersonal Group Therapy) that can be used independently or in conjunction to create
a "system of systems" approach. In this article, we have discussed how each of these
modalities can work together to enhance the overall therapeutic process. Combining these
three modalities, we propose that the ACT-GRO framework is able to offer an efficient and
effective approach.
We have also explained how these modalities can work together to support each other.
For example, the use of outdoor activities in OT can provide a unique context for practicing
the skills and strategies learned in ACT and IGT. The principles of the ACT-GRO framework
include using experiential learning, integrating the three modalities, and considering the
unique context of each individual. By utilizing these principles, the ACT-GRO framework
can provide a comprehensive and holistic approach to therapy.
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Authors
Adam Leighton, BSc1, Dotan Haim, MA2, Arnon Rolnick, Phd3, Miriam Ben Hirsch-
Gornemann, MD, MPH, PhD4
1
Lecturer, Ruppin Academic Center, Israel.
2
Lecturer, University of Haifa, Israel.
3
Emeritus lecturer, Ben Gurion University, Israel.
4
Head of Research and Evaluation, Heads UP CIO, UK.
Corresponding author:
Adam Leighton, 561 Hatamar St., Nehora, Israel.
Email: leighton.adam@ruppin365.net
Tel.:+972-33761175
EDITORS: Alexander Rose (Spain), Christiane Thiesen (Germany), Per Wijnands (The Netherlands)
E-Mail: editors@adventure-therapy-edition.com
Adventure Therapy Institute (ATI)

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Unfortunately, this was not always possible. If we forgot someone, we kindly ask the copyright holders to contact us.
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ACT-GRO FRAMEWORK an Integrated Conceptual and Practical Framework

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9IATC / 3GATE | SPECIAL EDITION

The ACT-GRO Framework – an integrated

Wilderness adventure therapy; group therapy; Acceptance and commitment therapy

www.journal-adventure-therapy.com International Journal of Adventure Therapy

Castonguay et al. (2015) described an approach to integrating therapies they called

International Journal of Adventure Therapy

3 ACT-GRO Framework Components (Systems)

3.1.1. Inclusion of ACT in the ACT-GRO Framework

3.1.2. Brief description of ACT

3.1.2.1. The Six Core Processes

a more adaptive approach than struggling to get rid of unpleasant feelings or

Self as context refers to the "observing self"(Harris, 2008), a non-judgemental state

Values, or as the authors frequently refer to as motivating values, relate to ones

Committed action refers to behaving according to one’s values allowing to create a

3.2. Outdoor Therapy

3.2.1. OT through a systems theory lens

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3.2.2. Brief description of Outdoor Therapy (OT)

Table 1: Key elements of Wilderness Therapy (based on Gabrielsen et al., 2018)

3. Connection to Socio-ecological factors such as place-based knowledge and land-based

International Journal of Adventure Therapy

3.3. Group Therapy

International Journal of Adventure Therapy

Traditionally, group therapy is conducted by one or two therapists, known as leaders or

3.3.1. Inclusion of the Interpersonal Group Therapy approach in the ACT-

Group therapy approaches differ in underlying theory, conceptualisation of group

3.3.2. Interpersonal Group Therapy (IGT)

An essential aspect of group therapy is the therapeutic value of relationships between

International Journal of Adventure Therapy

4 The ACT-GRO Framework

4.1. Integrating the three systems in the ACT-GRO Framework

To further understand how the ACT-GRO Framework operates as a system of systems, we

As an illustration, the activity of mountain climbing can be regarded as a challenge, which

International Journal of Adventure Therapy

Figure 1. Interaction of systems in the framework of the ACT-GRO Framework

ACT Group therapy •Development of socializing

International Journal of Adventure Therapy

support acceptance, defusion, self as

Examining a specific example, we can investigate how the therapeutic factor of

To illustrate, we consider a group cooking a meal outdoors when it unexpectedly starts to

International Journal of Adventure Therapy

Figure 2. Examining interaction of systems - rain whilst cooking outdoors example

Outdoor therapy •Challenge

ACT Group therapy

To further illustrate, we consider a group participating in a challenging activity, such as

4.2. Programme Structure

The ACT-GRO Framework is a structured program that includes 10-12 sessions of

International Journal of Adventure Therapy

Outdoor Suppor�ng group Experiences allow Suppor�ng skills

cohesion discovery, prac�cing assimila�on & group

Group Focus on group Enhances outdoor Focus on group

Focus on ACT - self Focus on all skills&

4.2.1. Core sessions

International Journal of Adventure Therapy

Group Outdoor ACT Psycho - Prac�ce &

X X Icebreakers / Check-in round (Duﬀy,2008)

Experien�al core exercise (the order can be

4.2.2. The reflection process

In the ACT-GRO Framework, we distinguish between two types of reflection; group-

International Journal of Adventure Therapy

The effectiveness of integrative psychotherapy approaches, such as the ACT-GRO

5.2. Participant compatibility

Participant/Patient compatibility is a crucial consideration when examining the different